Basic Information
| Provider Information | |||||||||
| NPI: | 1801204169 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MEAD | ||||||||
| FirstName: | DEXTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 351 E 45TH ST APT 5 | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112033152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3473447546 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3360 SHORE PKWY STE C1 | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112352716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187690405 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2014 | ||||||||
| LastUpdateDate: | 07/30/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.