Provider Demographics
NPI:1982912929
Name:CLUB MENTAL HEALTH COUNSELING SERVICES, P.C.
Entity Type:Organization
Organization Name:CLUB MENTAL HEALTH COUNSELING SERVICES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:B
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:718-873-3189
Mailing Address - Street 1:PO BOX 140695
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-0695
Mailing Address - Country:US
Mailing Address - Phone:781-873-3189
Mailing Address - Fax:718-982-8508
Practice Address - Street 1:272 ADA DR
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-1434
Practice Address - Country:US
Practice Address - Phone:718-873-3189
Practice Address - Fax:718-982-8508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-23
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001024-1101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty