Provider Demographics
NPI:1649481219
Name:INTENSIVE CASE MANAGEMENT PROGRAM
Entity type:Organization
Organization Name:INTENSIVE CASE MANAGEMENT PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CASE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DOREEN
Authorized Official - Middle Name:
Authorized Official - Last Name:DESMOND
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:631-853-2762
Mailing Address - Street 1:1841 BRENTWOOD RD
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-4625
Mailing Address - Country:US
Mailing Address - Phone:631-853-2762
Mailing Address - Fax:631-853-2779
Practice Address - Street 1:1841 BRENTWOOD RD
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-4625
Practice Address - Country:US
Practice Address - Phone:631-853-2762
Practice Address - Fax:631-853-2779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-25
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management