Provider Demographics
NPI:1386931632
Name:BUITRAGO, CARLOS A (CASAC)
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:A
Last Name:BUITRAGO
Suffix:
Gender:M
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11050
Mailing Address - Country:US
Mailing Address - Phone:516-767-1133
Mailing Address - Fax:516-767-3680
Practice Address - Street 1:225 MAIN STREET
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:NY
Practice Address - Zip Code:11050
Practice Address - Country:US
Practice Address - Phone:516-767-1133
Practice Address - Fax:516-767-3680
Is Sole Proprietor?:No
Enumeration Date:2011-07-07
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYCASAC-18793101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)