=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063717163
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHARE OF NEW SQUARE, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/20/2011
-----------------------------------------------------
Last Update Date | 01/20/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 286 N MAIN ST
-----------------------------------------------------
City | SPRING VALLEY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10977-3704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-354-3233
-----------------------------------------------------
Fax | 845-354-5472
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 118 CLINTON LN
-----------------------------------------------------
City | SPRING VALLEY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10977-1969
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-354-3233
-----------------------------------------------------
Fax | 845-354-5472
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. SHULIM GREENBERG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 845-354-3233
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 252Y00000X
-----------------------------------------------------
Taxonomy Name | Early Intervention Provider Agency
-----------------------------------------------------
License Number | 15905
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------