Basic Information
| Provider Information | |||||||||
| NPI: | 1366612335 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE CHILD CENTER OF NY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CLINIC PLUS - SOUTH JAMAICA | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 6002 QUEENS BLVD | ||||||||
| Address2: | |||||||||
| City: | WOODSIDE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113774973 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186517770 | ||||||||
| FaxNumber: | 7183968349 | ||||||||
| Practice Location | |||||||||
| Address1: | 6002 QUEENS BLVD | ||||||||
| Address2: | IRA MEYER CENTER | ||||||||
| City: | WOODSIDE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113774973 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189433470 | ||||||||
| FaxNumber: | 7186517227 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2008 | ||||||||
| LastUpdateDate: | 03/06/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COPPOLA | ||||||||
| AuthorizedOfficialFirstName: | JEAN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7186517770 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 00244371 | 05 | NY | MEDICAID |