Provider Demographics
NPI:1790995173
Name:BLANTON PEALE COMMUNITY COUNSELING CENTERS
Entity Type:Organization
Organization Name:BLANTON PEALE COMMUNITY COUNSELING CENTERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:PATER
Authorized Official - Last Name:ENNIS
Authorized Official - Suffix:
Authorized Official - Credentials:MDIV, LCSW
Authorized Official - Phone:718-253-9001
Mailing Address - Street 1:949 W END AVE APT 10F
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-3586
Mailing Address - Country:US
Mailing Address - Phone:212-662-8986
Mailing Address - Fax:
Practice Address - Street 1:FIRST UNITARIAN CHURCH
Practice Address - Street 2:50 MONROE PLACE
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201
Practice Address - Country:US
Practice Address - Phone:718-253-9001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000677101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty