Healthcare Provider Details

I. General information

NPI: 1720536337
Provider Name (Legal Business Name): SPECIALIZED ORGANIZATION FOR DISABILITIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2016
Last Update Date: 09/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 E 54TH ST
BROOKLYN NY
11203-4602
US

IV. Provider business mailing address

304 E 54TH ST
BROOKLYN NY
11203-4602
US

V. Phone/Fax

Practice location:
  • Phone: 347-489-5207
  • Fax:
Mailing address:
  • Phone: 347-489-5207
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number337712658
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number337712658
License Number StateNY

VIII. Authorized Official

Name: MISS TIFFANY DACRE
Title or Position: CEO
Credential: M.S
Phone: 347-489-5207