Provider Demographics
NPI:1578720595
Name:GARRASTEGUE, LUIS ANGEL (CASAC 24467)
Entity Type:Individual
Prefix:MR
First Name:LUIS
Middle Name:ANGEL
Last Name:GARRASTEGUE
Suffix:
Gender:M
Credentials:CASAC 24467
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 UNIVERSITY BLVD APT 5EW
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10453-3977
Mailing Address - Country:US
Mailing Address - Phone:646-369-3039
Mailing Address - Fax:
Practice Address - Street 1:625 W 140TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10031
Practice Address - Country:US
Practice Address - Phone:212-690-6202
Practice Address - Fax:212-690-2757
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-19
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
NY24467101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02740141Medicaid