Basic Information
| Provider Information | |||||||||
| NPI: | 1346680071 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BEHAVIORAL ENHANCEMENT & SUBSTANCE ABUSE MEDICINE TREATMENT PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 770 GRAND BLVD | ||||||||
| Address2: | SUITE 17 | ||||||||
| City: | DEER PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117295750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6313924357 | ||||||||
| FaxNumber: | 6313924358 | ||||||||
| Practice Location | |||||||||
| Address1: | 770 GRAND BLVD | ||||||||
| Address2: | SUITE 17 | ||||||||
| City: | DEER PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117295750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6313924357 | ||||||||
| FaxNumber: | 6313924358 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2013 | ||||||||
| LastUpdateDate: | 12/04/2013 | ||||||||
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| AuthorizedOfficialLastName: | PETRY | ||||||||
| AuthorizedOfficialFirstName: | DEBORAH | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | PROGRAM SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 6313924357 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | LCSW, CASAC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 140511797 | NY | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 140511797 | 01 | NY | OASAS | OTHER |