Basic Information
| Provider Information | |||||||||
| NPI: | 1457418337 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRANSITIONAL SERVICE FOR NEW YORK, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10-16 162ND STREET | ||||||||
| Address2: | |||||||||
| City: | WHITESTNO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113572124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187466647 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9027 SUTPHIN BLVD | ||||||||
| Address2: | |||||||||
| City: | JAMAICA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7185268400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2007 | ||||||||
| LastUpdateDate: | 05/12/2015 | ||||||||
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| AuthorizedOfficialLastName: | GRUBLER | ||||||||
| AuthorizedOfficialFirstName: | LARRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7187466647 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TRANSITIONAL SERVICE FOR NEW YORK, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | NY | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 00739762 | 05 | NY | MEDICAID |