Provider Demographics
NPI:1760406912
Name:FIFTH AVENUE CENTER
Entity Type:Organization
Organization Name:FIFTH AVENUE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:WEBBER
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:212-989-2990
Mailing Address - Street 1:332 E 84TH ST
Mailing Address - Street 2:APT. 5D
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-4443
Mailing Address - Country:US
Mailing Address - Phone:917-750-3594
Mailing Address - Fax:
Practice Address - Street 1:10 E 21ST ST
Practice Address - Street 2:FLOOR 7
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-7108
Practice Address - Country:US
Practice Address - Phone:212-989-2990
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002497261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center