Healthcare Provider Details

I. General information

NPI: 1013112358
Provider Name (Legal Business Name): ICD INTERNATIONAL CENTER FOR THE DISABLED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 E 106TH ST
NEW YORK NY
10029-4846
US

IV. Provider business mailing address

340 E 24TH ST
NEW YORK NY
10010-4019
US

V. Phone/Fax

Practice location:
  • Phone: 212-996-6127
  • Fax: 212-828-8453
Mailing address:
  • Phone: 212-585-6000
  • Fax: 212-585-6262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number6704100B
License Number StateNY

VIII. Authorized Official

Name: DR. LES HALPERT
Title or Position: CEO
Credential: PHD
Phone: 212-585-6009