Provider Demographics
NPI:1063775310
Name:THERACARE
Entity type:Organization
Organization Name:THERACARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPECIAL INSTRUCTOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:IRIS
Authorized Official - Middle Name:N/A
Authorized Official - Last Name:FUENTES
Authorized Official - Suffix:I
Authorized Official - Credentials:MSED
Authorized Official - Phone:718-597-5558
Mailing Address - Street 1:2510 WESTCHESTER AVENUE
Mailing Address - Street 2:102
Mailing Address - City:NEW YORK CITY
Mailing Address - State:NY
Mailing Address - Zip Code:10461-3512
Mailing Address - Country:US
Mailing Address - Phone:718-597-5558
Mailing Address - Fax:718-823-5494
Practice Address - Street 1:2510 WESTCHESTER AVE
Practice Address - Street 2:102
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-3512
Practice Address - Country:US
Practice Address - Phone:718-597-5558
Practice Address - Fax:718-823-5494
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-21
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY606668252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency