Provider Demographics
NPI:1649526120
Name:GITTENS, CARLENE M
Entity type:Individual
Prefix:
First Name:CARLENE
Middle Name:M
Last Name:GITTENS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1455 GENEVA LOOP
Mailing Address - Street 2:11C
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11239-2419
Mailing Address - Country:US
Mailing Address - Phone:718-942-0173
Mailing Address - Fax:
Practice Address - Street 1:1455 GENEVA LOOP
Practice Address - Street 2:11C
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11239-2419
Practice Address - Country:US
Practice Address - Phone:718-942-0173
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-02
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY252Y00000X, 251B00000X, 174400000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No252Y00000XAgenciesEarly Intervention Provider Agency
No251B00000XAgenciesCase Management
No171M00000XOther Service ProvidersCase Manager/Care Coordinator