Healthcare Provider Details

I. General information

NPI: 1184337404
Provider Name (Legal Business Name): EMMAS PLACE-STATEN ISLAND GRIEF AND LOSS CENTER FOR CHILDREN AND FAMIL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2023
Last Update Date: 01/02/2023
Certification Date: 01/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 RICHMOND TER # D
STATEN ISLAND NY
10301-1114
US

IV. Provider business mailing address

PO BOX 10311
STATEN ISLAND NY
10301-0311
US

V. Phone/Fax

Practice location:
  • Phone: 347-850-2322
  • Fax:
Mailing address:
  • Phone: 845-453-9690
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. MATTHEW RAYMOND KIEFER
Title or Position: BOARD SECRETARY
Credential:
Phone: 845-453-9690