Provider Demographics
NPI:1598083123
Name:ISON, THERON (CASAC)
Entity type:Individual
Prefix:
First Name:THERON
Middle Name:
Last Name:ISON
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 1:16005 76TH AVE
Mailing Address - Street 2:1B
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11366-1108
Mailing Address - Country:US
Mailing Address - Phone:347-564-3552
Mailing Address - Fax:
Practice Address - Street 1:16005 76TH AVE APT 1B
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11366-1108
Practice Address - Country:US
Practice Address - Phone:347-564-3552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-06
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY17336101YA0400X
NY0985691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00244019Medicaid