MEDICARE: KIDS CLUB LEO CORP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	222Q00000X	Developmental Therapist

General Provider Information

NPI Number	:	1043962376
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIDS CLUB LEO CORP

Provider Business Mailing Address
First Line	:	2427 GERRITSEN AVE FL 2
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11229-5903
Country	:	US
Telephone Number	:	646-269-0287
Fax Number	:

Provider Business Practice Location Address
First Line	:	2427 GERRITSEN AVE FL 2
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11229-5903
Country	:	US
Telephone Number	:	646-269-0287
Fax Number	:

Authorized Official
Title or Position	:	SPECIAL EDUCATION TEACHER
Name	:	MISS ALENA TROTSKAYA
Credential	:	MS.ED
Telephone Number	:	646-269-0287

Provider Enumeration Date	:	01/18/2022
Last Update Date	:	01/18/2022

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Directions to “KIDS CLUB LEO CORP ” Practice Location

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