Basic Information
| Provider Information | |||||||||
| NPI: | 1386663904 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTERBOROUGH DEVELOPMENTAL AND CONSULTATION CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 436 PROSPECT AVENUE | ||||||||
| Address2: | APT. 3L | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189097544 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1670-78 EAST 17TH STREET | ||||||||
| Address2: | 3RD FL. | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183751200 | ||||||||
| FaxNumber: | 7183823358 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | RUSK | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
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| AuthorizedOfficialTitleorPosition: | SOCIAL WORKER | ||||||||
| AuthorizedOfficialTelephone: | 7189097544 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 0718201 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.