Healthcare Provider Details

I. General information

NPI: 1669842845
Provider Name (Legal Business Name): NORTHSIDE CENTER FOR CHILD DEVELOPMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2015
Last Update Date: 10/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 5TH AVE 1ST FLOOR
NEW YORK NY
10029-3119
US

IV. Provider business mailing address

162 W 54TH ST APT. 8D
NEW YORK NY
10019-5345
US

V. Phone/Fax

Practice location:
  • Phone: 212-426-3400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. JEAN HOLLAND
Title or Position: DIRECTOR OF CLINIC PROGRAMS
Credential:
Phone: 212-426-3440