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General NPI Number Information
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NPI Number | 1154723559
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Entity Type | Organization
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Legal Business Name | ED180, INC
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Dates
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Enumeration Date | 09/17/2014
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Last Update Date | 09/17/2014
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Provider Practice Location Address
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Address Line | 300 GARDEN CITY PLZ SUITE 312
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City | GARDEN CITY
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State | NY
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Zip | 11530-3302
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Country | US
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Telephone | 516-280-3544
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Fax | 516-414-2544
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Provider Business Mailing Address
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Address Line | 300 GARDEN CITY PLZ SUITE 312
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City | GARDEN CITY
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State | NY
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Zip | 11530-3302
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Country | US
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Telephone | 516-280-3544
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Fax | 516-414-2544
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Authorized Official
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Title or Position | DIRECTOR
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Name | JEFFREY R DESARBO
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Credential | D.O.
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Telephone | 516-280-3544
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TP2701X
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Taxonomy Name | Group Psychotherapy Psychologist
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License Number |
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License Number State |
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