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General NPI Number Information
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NPI Number | 1144423062
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Entity Type | Organization
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Legal Business Name | STATEN ISLAND DEVELOPMENTAL DISABILITIES SERVICES OFFICE
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Dates
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Enumeration Date | 06/07/2007
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Last Update Date | 03/07/2023
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Provider Practice Location Address
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Address Line | 1150 FOREST HILL RD
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City | STATEN ISLAND
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State | NY
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Zip | 10314-6316
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Country | US
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Telephone | 718-983-5365
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Fax | 718-983-5462
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Provider Business Mailing Address
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Address Line | 1150 FOREST HILL RD
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City | STATEN ISLAND
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State | NY
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Zip | 10314-6316
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Country | US
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Telephone | 718-983-5365
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Fax | 718-983-5462
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Authorized Official
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Title or Position | DIRECTOR
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Name | DR. DAVID E BOOTH
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Credential | PH.D
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Telephone | 718-983-5321
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number | 006544
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License Number State | NY
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