Provider Demographics
NPI:1144423062
Name:STATEN ISLAND DEVELOPMENTAL DISABILITIES SERVICES OFFICE
Entity Type:Organization
Organization Name:STATEN ISLAND DEVELOPMENTAL DISABILITIES SERVICES OFFICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:E
Authorized Official - Last Name:BOOTH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:718-983-5321
Mailing Address - Street 1:1150 FOREST HILL RD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-6316
Mailing Address - Country:US
Mailing Address - Phone:718-983-5365
Mailing Address - Fax:718-983-5462
Practice Address - Street 1:1150 FOREST HILL RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-6316
Practice Address - Country:US
Practice Address - Phone:718-983-5365
Practice Address - Fax:718-983-5462
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006544320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01113928Medicaid
NY3351739OtherNCPDP PROVIDER ID
NY006544OtherSTATE LICENSE
NYAS8365694OtherDEA REGRISTRATION
NY=========OtherTAX ID