# SELF

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1649599135
- **Authorized official:** MS. GLORIA Z. MARTIN LPN (LPN)
- **Authorized official phone:** (347) 853-2849

## Contact information

- **Practice address:** 1965 LAFAYETTE AVE, APT. 1G, BRONX, NY 10473-2502
- **Practice address phone:** (718) 824-0605
- **Mailing address:** 1965 LAFAYETTE AVE, APT. 1G, BRONX, NY 10473-2502
- **Mailing address phone:** (718) 824-0605

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 320600000X | Intellectual and/or Developmental Disabilities Residential Treatment Facility | 273750-1 | NY | Yes |

## Other

- **Enumeration date:** 05/23/2010
- **Last updated:** 05/23/2010