Provider Demographics
NPI:1619128139
Name:INSTITUTE FOR COMMUNITY LIVING
Entity Type:Organization
Organization Name:INSTITUTE FOR COMMUNITY LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR CASE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CHEVON
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:VASSOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-290-2410
Mailing Address - Street 1:198 LINDEN BLVD
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11226-3627
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:718-856-6867
Practice Address - Street 1:198 LINDEN BLVD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11226-3627
Practice Address - Country:US
Practice Address - Phone:718-290-2410
Practice Address - Fax:718-856-6867
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-02
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01305004Medicaid