Provider Demographics
NPI:1013336262
Name:WALCOTT, PHILBERT (CASAC)
Entity Type:Individual
Prefix:
First Name:PHILBERT
Middle Name:
Last Name:WALCOTT
Suffix:
Gender:M
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3422 KNOX PLACE
Mailing Address - Street 2:APT. 2B
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467
Mailing Address - Country:US
Mailing Address - Phone:718-881-3905
Mailing Address - Fax:
Practice Address - Street 1:177 EAST 122ND STREET
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10035
Practice Address - Country:US
Practice Address - Phone:212-360-7116
Practice Address - Fax:212-829-5156
Is Sole Proprietor?:No
Enumeration Date:2014-04-15
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY17361101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)