Healthcare Provider Details

I. General information

NPI: 1760135511
Provider Name (Legal Business Name): BLUE SPECTRUM CANOPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2022
Last Update Date: 02/01/2022
Certification Date: 02/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1255 E 31ST ST
BROOKLYN NY
11210-4740
US

IV. Provider business mailing address

1255 E 31ST ST
BROOKLYN NY
11210-4740
US

V. Phone/Fax

Practice location:
  • Phone: 347-977-7095
  • Fax:
Mailing address:
  • Phone: 347-668-9113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: SIMCHA BENDET
Title or Position: DIRECTOR
Credential:
Phone: 347-977-7095