Provider Demographics
NPI:1427105857
Name:INSTITUTE FOR COMMUNITY LIVING , INC.
Entity type:Organization
Organization Name:INSTITUTE FOR COMMUNITY LIVING , INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:RENIE
Authorized Official - Middle Name:ELIZABETH MARIE
Authorized Official - Last Name:RONDON JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:718-855-7485
Mailing Address - Street 1:136 ROCKVILLE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11422-0000
Mailing Address - Country:US
Mailing Address - Phone:718-855-7485
Mailing Address - Fax:
Practice Address - Street 1:13607 BROOKVILLE BLVD
Practice Address - Street 2:
Practice Address - City:ROSEDALE
Practice Address - State:NY
Practice Address - Zip Code:11422-1525
Practice Address - Country:US
Practice Address - Phone:718-855-7485
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY057800251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health