Basic Information
| Provider Information | |||||||||
| NPI: | 1366854705 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE CHILD CENTER OF NY, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | QUEENS CHILD GUIDANCE CENTER | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6002 QUEENS BLVD | ||||||||
| Address2: | |||||||||
| City: | WOODSIDE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113774973 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186517770 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2837 29TH ST | ||||||||
| Address2: | PS 17 | ||||||||
| City: | LONG ISLAND CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 111022450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182781220 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2014 | ||||||||
| LastUpdateDate: | 05/20/2014 | ||||||||
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| AuthorizedOfficialLastName: | COPPOLA | ||||||||
| AuthorizedOfficialFirstName: | JEAN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF BILLING | ||||||||
| AuthorizedOfficialTelephone: | 7186517770 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 6734121E | NY | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 00244371 | 05 | NY | MEDICAID |