Healthcare Provider Details

I. General information

NPI: 1821768375
Provider Name (Legal Business Name): RED DOOR INDIVIDUALIZED LEARNING PROGRAM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2021
Last Update Date: 09/16/2021
Certification Date: 09/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 W COLUMBIA ST
HEMPSTEAD NY
11550-2411
US

IV. Provider business mailing address

30 W COLUMBIA ST
HEMPSTEAD NY
11550-2411
US

V. Phone/Fax

Practice location:
  • Phone: 516-385-2323
  • Fax: 516-481-4201
Mailing address:
  • Phone: 516-385-2323
  • Fax: 516-481-4201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. GREGORY DOMOND
Title or Position: PRESIDENT
Credential:
Phone: 516-654-8600