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General NPI Number Information
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NPI Number | 1386663904
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Entity Type | Organization
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Legal Business Name | INTERBOROUGH DEVELOPMENTAL AND CONSULTATION CENTER
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Dates
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Enumeration Date | 07/18/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1670-78 EAST 17TH STREET 3RD FL.
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City | BROOKLYN
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State | NY
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Zip | 11229
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Country | US
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Telephone | 718-375-1200
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Fax | 718-382-3358
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Provider Business Mailing Address
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Address Line | 436 PROSPECT AVENUE APT. 3L
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City | BROOKLYN
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State | NY
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Zip | 11215
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Country | US
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Telephone | 718-909-7544
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Fax |
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Authorized Official
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Title or Position | SOCIAL WORKER
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Name | MR. JAMES RUSK
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Credential |
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Telephone | 718-909-7544
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 0718201
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License Number State | NY
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