Basic Information
| Provider Information | |||||||||
| NPI: | 1033467014 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHILD CENTER OF NEW YORK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 115-15 SUTPHIN BLVD | ||||||||
| Address2: | |||||||||
| City: | JAMAICA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11434 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 11515 SUTPHIN BLVD | ||||||||
| Address2: | |||||||||
| City: | JAMAICA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114341020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186594000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2012 | ||||||||
| LastUpdateDate: | 09/10/2012 | ||||||||
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| AuthorizedOfficialLastName: | JONES | ||||||||
| AuthorizedOfficialFirstName: | RACQUEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 7186594000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LMSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 00244371 | 05 | NY | MEDICAID |