Provider Demographics
NPI:1427696061
Name:ELDERBERRY ICF
Entity type:Organization
Organization Name:ELDERBERRY ICF
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP BUSINESS DEVELOPMENT
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:MORACI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-707-8135
Mailing Address - Street 1:PO BOX 840
Mailing Address - Street 2:
Mailing Address - City:HARRIS
Mailing Address - State:NY
Mailing Address - Zip Code:12742-0840
Mailing Address - Country:US
Mailing Address - Phone:845-707-8135
Mailing Address - Fax:
Practice Address - Street 1:15 POEM PLACE
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:NY
Practice Address - Zip Code:12701
Practice Address - Country:US
Practice Address - Phone:845-707-8341
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SDTC THE CENTER FOR DISCOVERY INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-12-13
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY74670475OtherOFFICE FOR PEOPLE WITH DEVELOPMENTAL DISABILITIES