Healthcare Provider Details

I. General information

NPI: 1437563400
Provider Name (Legal Business Name): EATING DISORDER TREATMENT COLLABORATIVE/FEED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2014
Last Update Date: 06/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

366 N BROADWAY SUITE PHW-1
JERICHO NY
11753-2025
US

IV. Provider business mailing address

366 N BROADWAY SUITE PHW-1
JERICHO NY
11753-2025
US

V. Phone/Fax

Practice location:
  • Phone: 516-513-1284
  • Fax: 516-513-1285
Mailing address:
  • Phone: 516-513-1284
  • Fax: 516-513-1285

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: SONDRA KRONBERG
Title or Position: DIRECTOR, OWNER
Credential: MS,RD, CEDRD
Phone: 516-513-1284