Healthcare Provider Details

I. General information

NPI: 1457881443
Provider Name (Legal Business Name): COORDINATED BEHAVIORAL CARE IPA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 TELLER AVE
BRONX NY
10456-1002
US

IV. Provider business mailing address

123 WILLIAM ST FL 19
NEW YORK NY
10038-3804
US

V. Phone/Fax

Practice location:
  • Phone: 718-215-2100
  • Fax: 718-293-3815
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DANIKA MILLS
Title or Position: EXECUTIVE DIRECTOR
Credential: LCSW,LCAT
Phone: 646-930-8803