Healthcare Provider Details

I. General information

NPI: 1386181568
Provider Name (Legal Business Name): NEIGHBORHOOD CHANGE YOUTH ORGANIZATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2017
Last Update Date: 01/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

88 SENECA ST
STATEN ISLAND NY
10310-2334
US

IV. Provider business mailing address

88 SENECA ST
STATEN ISLAND NY
10310-2334
US

V. Phone/Fax

Practice location:
  • Phone: 646-600-1843
  • Fax:
Mailing address:
  • Phone: 646-600-1843
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number609775
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number609775
License Number StateNY

VIII. Authorized Official

Name: TAKISHA COLLINS
Title or Position: DIRECTOR
Credential:
Phone: 646-600-1843