MEDICARE: IC RESPONSE NY INC

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	103K00000X	Behavior Analyst	000468-1	NY
2	235Z00000X	Speech-Language Pathologist	024299-1	NY
3	174400000X	Specialist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1245739044
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IC RESPONSE NY INC

Provider Business Mailing Address
First Line	:	2615 AVENUE W
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11229-5041
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2615 AVENUE W
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11229-5041
Country	:	US
Telephone Number	:	646-670-3093
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	INNESSA CONTE
Credential	:
Telephone Number	:	646-670-3093

Provider Enumeration Date	:	02/07/2018
Last Update Date	:	02/07/2018

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Directions to “IC RESPONSE NY INC ” Practice Location

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