=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346730082
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLEVER KIDS CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2018
-----------------------------------------------------
Last Update Date | 02/28/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1073 ROSELLE PL
-----------------------------------------------------
City | WOODMERE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11598-1116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-479-5509
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1150 BRIGHTON BEACH AVE APT 2U
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11235-5950
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-479-5509
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MARINA KHASIDO MILLER
-----------------------------------------------------
Credential | MS
-----------------------------------------------------
Telephone | 646-479-5509
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 252Y00000X
-----------------------------------------------------
Taxonomy Name | Early Intervention Provider Agency
-----------------------------------------------------
License Number | 885776
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------