Healthcare Provider Details

I. General information

NPI: 1912100454
Provider Name (Legal Business Name): ICD INTERNATIONAL CENTER FOR THE DISABLED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2007
Last Update Date: 01/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 212-585-6000
  • Fax: 212-585-6262
Mailing address:
  • Phone: 212-585-6000
  • Fax: 212-585-6262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number090110619
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number6704100A
License Number StateNY

VIII. Authorized Official

Name: LES HALPERT
Title or Position: PRESIDENT AND CEO
Credential: PH.D.
Phone: 212-585-6009