Healthcare Provider Details

I. General information

NPI: 1902242910
Provider Name (Legal Business Name): KIDS ALTERNATIVE LEARNING & INTERVENTION SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2013
Last Update Date: 05/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

88 MADISON ST
MASTIC NY
11950-3811
US

IV. Provider business mailing address

88 MADISON ST
MASTIC NY
11950-3811
US

V. Phone/Fax

Practice location:
  • Phone: 917-518-2873
  • Fax: 631-399-5833
Mailing address:
  • Phone: 917-518-2873
  • Fax: 631-399-5833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number StateNY

VIII. Authorized Official

Name: MS. MARGARET DOMINIQUE-MCLAIN
Title or Position: PRESIDENT/CEO
Credential: LMSW
Phone: 917-518-2873