Provider Demographics
NPI:1386663904
Name:INTERBOROUGH DEVELOPMENTAL AND CONSULTATION CENTER
Entity Type:Organization
Organization Name:INTERBOROUGH DEVELOPMENTAL AND CONSULTATION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOCIAL WORKER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-909-7544
Mailing Address - Street 1:436 PROSPECT AVENUE
Mailing Address - Street 2:APT. 3L
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215
Mailing Address - Country:US
Mailing Address - Phone:718-909-7544
Mailing Address - Fax:
Practice Address - Street 1:1670-78 EAST 17TH STREET
Practice Address - Street 2:3RD FL.
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229
Practice Address - Country:US
Practice Address - Phone:718-375-1200
Practice Address - Fax:718-382-3358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY07182011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty