MEDICARE: PSYCHOTHERAPY AND QUALITY ASSURANCE SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251C00000X	Developmentally Disabled Services Day Training Agency

General Provider Information

NPI Number	:	1528106549
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PSYCHOTHERAPY AND QUALITY ASSURANCE SERVICES

Provider Business Mailing Address
First Line	:	83 NEWPORT ST
Second Line	:	2 R
City	:	BROOKLYN
State	:	NY
Zip	:	11212-4959
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4012 CHURCH AVE
Second Line	:	# 2
City	:	BROOKLYN
State	:	NY
Zip	:	11203-2917
Country	:	US
Telephone Number	:	718-282-0777
Fax Number	:

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	JASON FLEMMING
Credential	:
Telephone Number	:	718-282-0777

Provider Enumeration Date	:	02/02/2007
Last Update Date	:	06/17/2008

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