Provider Demographics
NPI:1598158552
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:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:XOCHITL
Authorized Official - Middle Name:
Authorized Official - Last Name:ROA
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-R
Authorized Official - Phone:718-388-5176
Mailing Address - Street 1:819 GRAND ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11211-5001
Mailing Address - Country:US
Mailing Address - Phone:718-388-5176
Mailing Address - Fax:
Practice Address - Street 1:819 GRAND ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11211-5001
Practice Address - Country:US
Practice Address - Phone:718-388-5176
Practice Address - Fax:718-388-6159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-13
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health