Provider Demographics
NPI:1285948570
Name:BETHABRAHAM HOSPITAL
Entity type:Organization
Organization Name:BETHABRAHAM HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OTA/OTA
Authorized Official - Prefix:MS
Authorized Official - First Name:LORNA
Authorized Official - Middle Name:DECARLA
Authorized Official - Last Name:INNIS
Authorized Official - Suffix:
Authorized Official - Credentials:OTA
Authorized Official - Phone:646-415-1121
Mailing Address - Street 1:3936 BARNES AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10466-4313
Mailing Address - Country:US
Mailing Address - Phone:646-415-1121
Mailing Address - Fax:
Practice Address - Street 1:3936 BARNES AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10466-4313
Practice Address - Country:US
Practice Address - Phone:646-415-1121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-29
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006625-1251300000X, 252Y00000X, 302R00000X, 320900000X, 273Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273Y00000XHospital UnitsRehabilitation Unit
No251300000XAgenciesLocal Education Agency (LEA)
No252Y00000XAgenciesEarly Intervention Provider Agency
No302R00000XManaged Care OrganizationsHealth Maintenance Organization
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities