Basic Information
Provider Information | |||||||||
NPI: | 1588611842 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | INTERBOROUGH DEVELOPMENTAL AND CONSULTATION CENTER, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LSA RECOVERY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1623 KINGS HWY | ||||||||
Address2: |   | ||||||||
City: | BROOKLYN | ||||||||
State: | NY | ||||||||
PostalCode: | 112291209 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7183751200 | ||||||||
FaxNumber: | 7183823358 | ||||||||
Practice Location | |||||||||
Address1: | 1623 KINGS HWY | ||||||||
Address2: |   | ||||||||
City: | BROOKLYN | ||||||||
State: | NY | ||||||||
PostalCode: | 112291209 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7183751200 | ||||||||
FaxNumber: | 7183823358 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/30/2006 | ||||||||
LastUpdateDate: | 04/19/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GERSTEN | ||||||||
AuthorizedOfficialFirstName: | STEPHEN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 9292737601 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | PSY.D. | ||||||||
NPICertificationDate: | 04/19/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 104100000X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker |   | 251B00000X | 6989100A | NY | Y |   | Agencies | Case Management |   |
ID Information
ID | Type | State | Issuer | Description | 00245318 | 05 | NY |   | MEDICAID |