Basic Information
| Provider Information | |||||||||
| NPI: | 1154669661 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DAMON HOUSE NEW YORK, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1285 ROCKAWAY AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112362330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9177417157 | ||||||||
| FaxNumber: | 7182575560 | ||||||||
| Practice Location | |||||||||
| Address1: | 1285 ROCKAWAY AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112362330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9177417157 | ||||||||
| FaxNumber: | 7182575560 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2013 | ||||||||
| LastUpdateDate: | 09/06/2016 | ||||||||
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| AuthorizedOfficialLastName: | LERNER | ||||||||
| AuthorizedOfficialFirstName: | JANET | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7188580202 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PH.D, LCSW-R | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
ID Information
| ID | Type | State | Issuer | Description | 1154669661 | 01 | NY | NPI# | OTHER |