Provider Demographics
NPI:1174785877
Name:GEMELLE, CARLY (CASAC-T)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:GEMELLE
Suffix:
Gender:F
Credentials:CASAC-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:186 MESEROLE ST
Mailing Address - Street 2:APT 6
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11206-2136
Mailing Address - Country:US
Mailing Address - Phone:917-686-9878
Mailing Address - Fax:
Practice Address - Street 1:8 E 3RD ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-8908
Practice Address - Country:US
Practice Address - Phone:212-763-0596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-25
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTBA101Y00000X, 101YA0400X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYTBAOtherCASAC-T