Provider Demographics
NPI:1891187852
Name:SOLE PROPRIETOR
Entity Type:Organization
Organization Name:SOLE PROPRIETOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ABSS
Authorized Official - Prefix:MR
Authorized Official - First Name:BRENDAN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:CANAVAN
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:516-770-2383
Mailing Address - Street 1:610 WILLIS AVE APT 1F
Mailing Address - Street 2:
Mailing Address - City:WILLISTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11596-1221
Mailing Address - Country:US
Mailing Address - Phone:516-770-2383
Mailing Address - Fax:
Practice Address - Street 1:610 WILLIS AVE APT 1F
Practice Address - Street 2:
Practice Address - City:WILLISTON PARK
Practice Address - State:NY
Practice Address - Zip Code:11596-1221
Practice Address - Country:US
Practice Address - Phone:516-770-2383
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-28
Last Update Date:2015-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY437022101251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health