1205972601 NPI number — SOUTH SHORE CHILD ASSOCIATION INCORPORATED

Table of content: (NPI 1205972601)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205972601 NPI number — SOUTH SHORE CHILD ASSOCIATION INCORPORATED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH SHORE CHILD ASSOCIATION INCORPORATED
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SOUTH SHORE GUIDANCE CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205972601
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/19/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
114 CHURCH STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FREEPORT
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11520-3731
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-868-3030
Provider Business Mailing Address Fax Number:
516-868-3374

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
114 CHURCH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FREEPORT
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11520-3731
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-868-3030
Provider Business Practice Location Address Fax Number:
516-868-3374
Provider Enumeration Date:
01/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
RICHMAN
Authorized Official First Name:
NATALIE
Authorized Official Middle Name:
M
Authorized Official Title or Position:
REVENUE MANAGEMENT ADMINISTRATOR
Authorized Official Telephone Number:
516-739-7733

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X , with the licence number:  160310993 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 251S00000X , with the licence number: 080310993 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00336943 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 080310993 . This is a "OASAS OPERATING CERTIFICA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 03001127 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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