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General NPI Number Information
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NPI Number | 1376807222
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Entity Type | Organization
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Legal Business Name | LB411
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Dates
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Enumeration Date | 06/26/2012
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Last Update Date | 06/26/2012
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Provider Practice Location Address
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Address Line | 370 SAND LN
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City | STATEN ISLAND
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State | NY
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Zip | 10305-4551
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Country | US
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Telephone | 347-579-8474
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Fax |
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Provider Business Mailing Address
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Address Line | 370 SAND LN
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City | STATEN ISLAND
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State | NY
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Zip | 10305-4551
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | TSHH, MS. ED.
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Name | ISABELLA DEANGELIS
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Credential |
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Telephone | 347-579-8474
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 252Y00000X
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Taxonomy Name | Early Intervention Provider Agency
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License Number | 052747980
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License Number State | NY
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