Provider Demographics
NPI:1407118441
Name:CITY PRO GROUP
Entity Type:Organization
Organization Name:CITY PRO GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TEACHER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:KLYACHKO
Authorized Official - Suffix:
Authorized Official - Credentials:MS,ED
Authorized Official - Phone:917-696-7319
Mailing Address - Street 1:1975 84TH ST
Mailing Address - Street 2:APTA7
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11214-3065
Mailing Address - Country:US
Mailing Address - Phone:917-696-7319
Mailing Address - Fax:
Practice Address - Street 1:1975 84TH ST
Practice Address - Street 2:APT. A7
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11214-3065
Practice Address - Country:US
Practice Address - Phone:917-696-7319
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-14
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174.400000X252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY=========Medicaid