Healthcare Provider Details

I. General information

NPI: 1457565087
Provider Name (Legal Business Name): NORTH SHORE CREATIVE REHABILITATION CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 08/02/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

781 MIDDLE NECK RD
GREAT NECK NY
11024-1929
US

IV. Provider business mailing address

781 MIDDLE NECK RD
GREAT NECK NY
11024-1929
US

V. Phone/Fax

Practice location:
  • Phone: 516-482-1550
  • Fax:
Mailing address:
  • Phone: 516-482-1550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number7625300A
License Number StateNY

VIII. Authorized Official

Name: EDWARD REGENSBURG
Title or Position: EXECUTIVE DIRECTOR
Credential: LCAT
Phone: 516-482-1903