Provider Demographics
NPI:1659862738
Name:CANADY, JEFFREY KIEWHON (CASAC-T)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:KIEWHON
Last Name:CANADY
Suffix:
Gender:M
Credentials:CASAC-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2698 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10030-1219
Mailing Address - Country:US
Mailing Address - Phone:347-583-0718
Mailing Address - Fax:212-947-2424
Practice Address - Street 1:1369 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10018-7200
Practice Address - Country:US
Practice Address - Phone:212-268-8830
Practice Address - Fax:212-947-2424
Is Sole Proprietor?:No
Enumeration Date:2018-05-23
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY34585101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)