Healthcare Provider Details

I. General information

NPI: 1750622478
Provider Name (Legal Business Name): MR. ROBERTO DONALDSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2013
Last Update Date: 03/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3524 83RD ST QUEENS COMMUNITY LIVING PROGRAM (3RD FLOOR)
JACKSON HEIGHTS NY
11372-5229
US

IV. Provider business mailing address

525 ROCKAWAY PKWY APT B42
BROOKLYN NY
11212-3100
US

V. Phone/Fax

Practice location:
  • Phone: 718-639-0700
  • Fax: 718-639-7684
Mailing address:
  • Phone: 718-840-7925
  • Fax: 718-639-7684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: