Provider Demographics
NPI:1508930694
Name:CG&D ALCOHOLISM AND ADDICTION SERVICES, INC.
Entity Type:Organization
Organization Name:CG&D ALCOHOLISM AND ADDICTION SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR, CASAC, LPC
Authorized Official - Prefix:MRS
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:G
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-691-0769
Mailing Address - Street 1:45 DIXON AVE
Mailing Address - Street 2:
Mailing Address - City:AMITYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11701-2809
Mailing Address - Country:US
Mailing Address - Phone:631-691-0769
Mailing Address - Fax:
Practice Address - Street 1:45 DIXON AVE
Practice Address - Street 2:
Practice Address - City:AMITYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11701-2809
Practice Address - Country:US
Practice Address - Phone:631-691-0769
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
338178OtherVALUE OPTIONS
NY02153551Medicaid
NYWEW711Medicare PIN