Healthcare Provider Details

I. General information

NPI: 1952829988
Provider Name (Legal Business Name): CRESTWOOD EARLY INTERVENTION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2017
Last Update Date: 08/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 CRESTWOOD DRIVE
PLAINVIEW NY
11803
US

IV. Provider business mailing address

10 CRESTWOOD DR
PLAINVIEW NY
11803-6408
US

V. Phone/Fax

Practice location:
  • Phone: 917-796-8106
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number StateNY

VII. Legacy identifiers

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

VIII. Authorized Official

Name: MARJORIE ELISE TIRSUN
Title or Position: DIRECTOR
Credential:
Phone: 917-796-8106