Provider Demographics
NPI:1942359476
Name:CAMELOT OF STATEN ISLAND, INC.
Entity Type:Organization
Organization Name:CAMELOT OF STATEN ISLAND, INC.
Other - Org Name:CAMELOT COUNSELING CENTERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LUKE
Authorized Official - Middle Name:J
Authorized Official - Last Name:NASTA
Authorized Official - Suffix:
Authorized Official - Credentials:MPA, CASAC
Authorized Official - Phone:718-356-5100
Mailing Address - Street 1:4442 ARTHUR KILL RD STE 4
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10309-1321
Mailing Address - Country:US
Mailing Address - Phone:718-356-5100
Mailing Address - Fax:718-981-8309
Practice Address - Street 1:263 PORT RICHMOND AVENUE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10302
Practice Address - Country:US
Practice Address - Phone:718-981-8117
Practice Address - Fax:718-981-8309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01292768Medicaid