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General NPI Number Information
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NPI Number | 1952736076
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Entity Type | Organization
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Legal Business Name | PEDERSON KRAG
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Dates
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Enumeration Date | 09/09/2013
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Last Update Date | 09/09/2013
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Provider Practice Location Address
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Address Line | 3600 ROUTE 112
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City | CORAM
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State | NY
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Zip | 11727-4116
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Country | US
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Telephone | 631-853-8511
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Fax |
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Provider Business Mailing Address
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Address Line | 102 ROMITO CT
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City | BETHPAGE
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State | NY
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Zip | 11714-3221
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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 | SOCIAL WORKER
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Name | MICHELLE SAVINO
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Credential |
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Telephone | 631-853-8511
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 086683
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License Number State | NY
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