Basic Information
Provider Information | |||||||||
NPI: | 1063968428 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | UNITED CEREBRAL PALSY ASSOC OF NYS INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CEREBRAL PALSY ASSOC OF NYS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 330 W 34TH ST FL 15 | ||||||||
Address2: |   | ||||||||
City: | NEW YORK | ||||||||
State: | NY | ||||||||
PostalCode: | 100012406 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2129475770 | ||||||||
FaxNumber: | 2123561348 | ||||||||
Practice Location | |||||||||
Address1: | 3730 SHORE PKWY | ||||||||
Address2: |   | ||||||||
City: | BROOKLYN | ||||||||
State: | NY | ||||||||
PostalCode: | 112351718 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7187698836 | ||||||||
FaxNumber: | 7183680418 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/26/2016 | ||||||||
LastUpdateDate: | 08/26/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MANDELKOW | ||||||||
AuthorizedOfficialFirstName: | THOMAS | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 2129475770 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310500000X |   |   | N |   | Nursing & Custodial Care Facilities | Intermediate Care Facility, Mental Illness |   | 313M00000X |   |   | N |   | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |   | 315P00000X |   |   | Y |   | Nursing & Custodial Care Facilities | Intermediate Care Facility, Mentally Retarded |   |
No ID Information.