Provider Demographics
NPI:1083980924
Name:DEPARTMENT OF EDUCATION
Entity Type:Organization
Organization Name:DEPARTMENT OF EDUCATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:PHYLLIS
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:FORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-556-1820
Mailing Address - Street 1:155 TOMPKINS AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10304-2601
Mailing Address - Country:US
Mailing Address - Phone:718-556-1820
Mailing Address - Fax:
Practice Address - Street 1:155 TOMPKINS AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10304-2601
Practice Address - Country:US
Practice Address - Phone:718-556-1820
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-26
Last Update Date:2012-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021206-1251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)