Provider Demographics
NPI:1770011314
Name:ICL HEALTHCARE CHOICES INC
Entity Type:Organization
Organization Name:ICL HEALTHCARE CHOICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SIEBEL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:718-234-0073
Mailing Address - Street 1:6209 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11204-2702
Mailing Address - Country:US
Mailing Address - Phone:718-234-0073
Mailing Address - Fax:718-236-8456
Practice Address - Street 1:179 JAMAICA AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11207-2049
Practice Address - Country:US
Practice Address - Phone:929-267-5354
Practice Address - Fax:929-267-5340
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7001299R261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02186390Medicaid
NYW86751OtherPART B