Provider Demographics
NPI:1639484298
Name:CHILDREN'S DEVELOPMENT GROUP FOR SPEECH, OCCUPATIONAL, AND PHYSICAL TH
Entity Type:Organization
Organization Name:CHILDREN'S DEVELOPMENT GROUP FOR SPEECH, OCCUPATIONAL, AND PHYSICAL TH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR/PLLC MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARGI
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:MA,CCC-SLP,CAS
Authorized Official - Phone:518-578-4912
Mailing Address - Street 1:1717 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:KEESEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12944-3619
Mailing Address - Country:US
Mailing Address - Phone:518-578-4912
Mailing Address - Fax:518-834-7072
Practice Address - Street 1:1717 FRONT ST
Practice Address - Street 2:
Practice Address - City:KEESEVILLE
Practice Address - State:NY
Practice Address - Zip Code:12944-3619
Practice Address - Country:US
Practice Address - Phone:518-578-4912
Practice Address - Fax:518-834-7072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-07
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008810-1252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY25821OtherNYSDOH