Provider Demographics
NPI:1821467788
Name:CREEDMOOR PSYCHIATRIC CENTER
Entity Type:Organization
Organization Name:CREEDMOOR PSYCHIATRIC CENTER
Other - Org Name:NYS
Other - Org Type:Other Name
Authorized Official - Title/Position:REGISTERED NURSE
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:GERMAINE
Authorized Official - Last Name:LAROQUE
Authorized Official - Suffix:
Authorized Official - Credentials:REGISTERED NURSE
Authorized Official - Phone:516-305-5787
Mailing Address - Street 1:137 HEATHCOTE RD
Mailing Address - Street 2:
Mailing Address - City:ELMONT
Mailing Address - State:NY
Mailing Address - Zip Code:11003-2005
Mailing Address - Country:US
Mailing Address - Phone:516-305-5787
Mailing Address - Fax:
Practice Address - Street 1:137 HEATHCOTE RD
Practice Address - Street 2:
Practice Address - City:ELMONT
Practice Address - State:NY
Practice Address - Zip Code:11003-2005
Practice Address - Country:US
Practice Address - Phone:516-305-5787
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-22
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY22-567790251B00000X
NY567790251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management