Provider Demographics
NPI:1154723559
Name:ED180, INC
Entity type:Organization
Organization Name:ED180, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:R
Authorized Official - Last Name:DESARBO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:516-280-3544
Mailing Address - Street 1:300 GARDEN CITY PLZ
Mailing Address - Street 2:SUITE 312
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-3302
Mailing Address - Country:US
Mailing Address - Phone:516-280-3544
Mailing Address - Fax:516-414-2544
Practice Address - Street 1:300 GARDEN CITY PLZ
Practice Address - Street 2:SUITE 312
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-3302
Practice Address - Country:US
Practice Address - Phone:516-280-3544
Practice Address - Fax:516-414-2544
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-17
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Single Specialty