Provider Demographics
NPI:1942565676
Name:CRUSOE, IRVIN (TEACHER)
Entity Type:Individual
Prefix:MR
First Name:IRVIN
Middle Name:
Last Name:CRUSOE
Suffix:
Gender:M
Credentials:TEACHER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:192 BRADHURST AVE
Mailing Address - Street 2:SUITE 26
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10039-1406
Mailing Address - Country:US
Mailing Address - Phone:646-765-7068
Mailing Address - Fax:212-281-1827
Practice Address - Street 1:192 BRADHURST AVE
Practice Address - Street 2:SUITE 26
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10039-1406
Practice Address - Country:US
Practice Address - Phone:646-765-7068
Practice Address - Fax:212-281-1827
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-09
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY21159174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist