Healthcare Provider Details

I. General information

NPI: 1407359482
Provider Name (Legal Business Name): MY1TEACHER CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2018
Last Update Date: 03/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1737 E 17TH ST
BROOKLYN NY
11229-2101
US

IV. Provider business mailing address

1737 E 17TH ST
BROOKLYN NY
11229-2101
US

V. Phone/Fax

Practice location:
  • Phone: 718-614-0702
  • Fax:
Mailing address:
  • Phone: 718-614-0702
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MRS. TATYANA ESTERKINA
Title or Position: SI/ABA PROVIDER
Credential: MS SP ED
Phone: 718-614-0702