Individual
KEVIN BANTUM
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
1041 BERGEN ST, BROOKLYN, NY 11216-3307
(718) 771-0760
Mailing address
1041 BERGEN ST, BROOKLYN, NY 11216-3307
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00004567
—
NY
Enumeration date
12/04/2019
Last updated
12/04/2019
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