Healthcare Provider Details

I. General information

NPI: 1629383484
Provider Name (Legal Business Name): CSEDNY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2010
Last Update Date: 08/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 FULTON AVE
HEMPSTEAD NY
11550-3718
US

IV. Provider business mailing address

509 JARVIS AVE
FAR ROCKAWAY NY
11691-5442
US

V. Phone/Fax

Practice location:
  • Phone: 516-481-0052
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number584123-1
License Number StateNY

VIII. Authorized Official

Name: MRS. BRENDA SPORN
Title or Position: NURSE
Credential: RN
Phone: 516-481-0052