Provider Demographics
NPI:1649599135
Name:SELF
Entity Type:Organization
Organization Name:SELF
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPN
Authorized Official - Prefix:MS
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:Z
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:347-853-2849
Mailing Address - Street 1:1965 LAFAYETTE AVE
Mailing Address - Street 2:APT. 1G
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10473-2502
Mailing Address - Country:US
Mailing Address - Phone:718-824-0605
Mailing Address - Fax:
Practice Address - Street 1:1965 LAFAYETTE AVE
Practice Address - Street 2:APT. 1G
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10473-2502
Practice Address - Country:US
Practice Address - Phone:718-824-0605
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-23
Last Update Date:2010-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY273750-1320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities