Basic Information
| Provider Information | |||||||||
| NPI: | 1922628155 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THERACARE MANAGED SERVICES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1133 WESTCHESTER AVE. | ||||||||
| Address2: | N230 | ||||||||
| City: | WHITE PLAINS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 106043516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2125642350 | ||||||||
| FaxNumber: | 2125642578 | ||||||||
| Practice Location | |||||||||
| Address1: | 67 WALNUT AVE | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | CLARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070661640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8556818555 | ||||||||
| FaxNumber: | 9145602102 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2020 | ||||||||
| LastUpdateDate: | 04/17/2020 | ||||||||
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| AuthorizedOfficialLastName: | MCCARTHY | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | CAROLINE | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF CONTRACT DEVELOPMENT | ||||||||
| AuthorizedOfficialTelephone: | 2125642350 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | THERACARE OF NEW YORK, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | 04/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 106S00000X | N | 193200000X MULTI-SPECIALTY GROUP | 103K00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.