Healthcare Provider Details

I. General information

NPI: 1518465277
Provider Name (Legal Business Name): EARLY INTERVENTION LCSW SERVICES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2018
Last Update Date: 01/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 ROGERS ST
ULSTER PARK NY
12487-5015
US

IV. Provider business mailing address

220 ROGERS ST
ULSTER PARK NY
12487-5015
US

V. Phone/Fax

Practice location:
  • Phone: 845-485-7237
  • Fax:
Mailing address:
  • Phone: 845-339-2462
  • Fax: 845-339-2462

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number04126401
License Number StateNY

VIII. Authorized Official

Name: MS. DEBORAH LYNNE HARADON
Title or Position: PRESIDENT
Credential: LCSW
Phone: 845-485-7237