Basic Information
Provider Information | |||||||||
NPI: | 1346491230 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | INSTITUTE FOR COMMUNITY LIVING | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 40 RECTOR STREET | ||||||||
Address2: |   | ||||||||
City: | NEW YORK | ||||||||
State: | NY | ||||||||
PostalCode: | 100061705 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2123853030 | ||||||||
FaxNumber: | 2123749225 | ||||||||
Practice Location | |||||||||
Address1: | 161 EMERSON PLACE | ||||||||
Address2: |   | ||||||||
City: | BROOKLYN | ||||||||
State: | NY | ||||||||
PostalCode: | 11205 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7186361463 | ||||||||
FaxNumber: | 7186361710 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/09/2008 | ||||||||
LastUpdateDate: | 10/09/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HOWARD | ||||||||
AuthorizedOfficialFirstName: | DEWEY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 2123853030 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | CPA | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X |   |   | Y |   | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |   |
No ID Information.