Provider Demographics
NPI:1023212818
Name:UNITED CEREBRAL POLSY
Entity Type:Organization
Organization Name:UNITED CEREBRAL POLSY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PTA
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:PRADIEU
Authorized Official - Suffix:
Authorized Official - Credentials:PTA
Authorized Official - Phone:718-645-6454
Mailing Address - Street 1:307 MARTENSE ST APT C7
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11226-4225
Mailing Address - Country:US
Mailing Address - Phone:718-484-3678
Mailing Address - Fax:
Practice Address - Street 1:121 LAKE ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11223-2734
Practice Address - Country:US
Practice Address - Phone:718-645-6454
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0028151315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY021087Medicare UPIN