Basic Information
| Provider Information | |||||||||
| NPI: | 1801945738 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE CHILD CENTER OF NY, INC. | ||||||||
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| OtherOrganizationName: | WOODSIDE CLINIC | ||||||||
| 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 | ||||||||
| FaxNumber: | 7186515029 | ||||||||
| Practice Location | |||||||||
| Address1: | 6714 41ST AVE | ||||||||
| Address2: | |||||||||
| City: | WOODSIDE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113773790 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184584243 | ||||||||
| FaxNumber: | 7184584481 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2007 | ||||||||
| LastUpdateDate: | 12/19/2013 | ||||||||
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| AuthorizedOfficialLastName: | COPPOLA | ||||||||
| AuthorizedOfficialFirstName: | JEAN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF BILLING | ||||||||
| AuthorizedOfficialTelephone: | 7186517770 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 7403085 | 01 | NY | GHI | OTHER | WV0071 | 01 | NY | BLUE CROSS BLUE SHIELD | OTHER | 00244371 | 05 | NY | MEDICAID |