Healthcare Provider Details

I. General information

NPI: 1285948570
Provider Name (Legal Business Name): BETHABRAHAM HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2010
Last Update Date: 07/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3936 BARNES AVE
BRONX NY
10466-4313
US

IV. Provider business mailing address

3936 BARNES AVE
BRONX NY
10466-4313
US

V. Phone/Fax

Practice location:
  • Phone: 646-415-1121
  • Fax:
Mailing address:
  • Phone: 646-415-1121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number006625-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number006625-1
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number006625-1
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number006625-1
License Number StateNY
# 5
Primary TaxonomyY
Taxonomy Code273Y00000X
TaxonomyRehabilitation Hospital Unit
License Number006625-1
License Number StateNY

VIII. Authorized Official

Name: MS. LORNA DECARLA INNIS
Title or Position: OTA/OTA
Credential: OTA
Phone: 646-415-1121