Provider Demographics
NPI:1013372051
Name:Q.V.C.M.H. J-CAP
Entity Type:Organization
Organization Name:Q.V.C.M.H. J-CAP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHEIF EXCUTIVE OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:718-712-1100
Mailing Address - Street 1:11630 SUTPHIN BLVD
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11434-1527
Mailing Address - Country:US
Mailing Address - Phone:718-322-2500
Mailing Address - Fax:718-322-1881
Practice Address - Street 1:11630 SUTPHIN BLVD
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11434-1527
Practice Address - Country:US
Practice Address - Phone:718-322-2500
Practice Address - Fax:718-322-1881
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:QUEENS VILLAGE COMMITTEE FOR MENTAL HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-12-17
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY8492324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY8492OtherLICENSE