Provider Demographics
NPI:1548623424
Name:25 CHAPEL STREET
Entity type:Organization
Organization Name:25 CHAPEL STREET
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LORIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-398-0153
Mailing Address - Street 1:301 W 130TH ST
Mailing Address - Street 2:APT 3C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10027-1813
Mailing Address - Country:US
Mailing Address - Phone:646-542-3980
Mailing Address - Fax:
Practice Address - Street 1:25 CHAPEL ST
Practice Address - Street 2:SUITE 901
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-1952
Practice Address - Country:US
Practice Address - Phone:718-398-0153
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-30
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY094063302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization