Provider Demographics
NPI:1093832545
Name:WEST 12TH STREET ICL
Entity Type:Organization
Organization Name:WEST 12TH STREET ICL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:DEWEY
Authorized Official - Middle Name:H
Authorized Official - Last Name:HOWARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-385-3030
Mailing Address - Street 1:125 BROAD STREET
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10004-2400
Mailing Address - Country:US
Mailing Address - Phone:212-385-3030
Mailing Address - Fax:917-831-4451
Practice Address - Street 1:2372 W 12TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11223-5734
Practice Address - Country:US
Practice Address - Phone:718-373-6019
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01427036Medicaid