Provider Demographics
NPI:1063671774
Name:CREEDMOOR PSYCHIATRIC CENTER
Entity Type:Organization
Organization Name:CREEDMOOR PSYCHIATRIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXAC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:IVERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-264-4000
Mailing Address - Street 1:7925 WINCHESTER BLVD
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11427
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7925 WINCHESTER BLVD
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11427
Practice Address - Country:US
Practice Address - Phone:718-264-5024
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE OF NEW YORK
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-06
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital