Basic Information
| Provider Information | |||||||||
| NPI: | 1730337049 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE CHILD CENTER OF NY | ||||||||
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| OtherOrganizationName: | IS 59 | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6002 QUEENS BLVD | ||||||||
| Address2: | LOWER LEVEL | ||||||||
| City: | WOODSIDE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113774973 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186517770 | ||||||||
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| Practice Location | |||||||||
| Address1: | 18998 RIDGEDALE ST | ||||||||
| Address2: | ROOM 116C | ||||||||
| City: | SPRINGFIELD GARDENS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186594000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2008 | ||||||||
| LastUpdateDate: | 08/29/2008 | ||||||||
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| AuthorizedOfficialLastName: | COPPOLA | ||||||||
| AuthorizedOfficialFirstName: | JEAN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7186517770 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X | 6734122F | NY | Y | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 7403085 | 01 | NY | GHI | OTHER | 00244371 | 05 | NY | MEDICAID | WV0071 | 01 | NY | BLUE CROSS/BLUE SHIELD | OTHER |