Provider Demographics
NPI:1386870202
Name:CATHOLIC CHARITIES DAY TREATMENT COMMACK
Entity type:Organization
Organization Name:CATHOLIC CHARITIES DAY TREATMENT COMMACK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-733-7040
Mailing Address - Street 1:90 CHERRY LN
Mailing Address - Street 2:
Mailing Address - City:HICKSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11801-6232
Mailing Address - Country:US
Mailing Address - Phone:516-733-7040
Mailing Address - Fax:
Practice Address - Street 1:155 INDIAN HEAD RD
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-2212
Practice Address - Country:US
Practice Address - Phone:631-543-6200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-05
Last Update Date:2009-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00668864Medicaid