Provider Demographics
NPI:1831463249
Name:THERACARE
Entity type:Organization
Organization Name:THERACARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ABA SERVICE PROVIDER
Authorized Official - Prefix:MS
Authorized Official - First Name:TRECIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:KELLOGG
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:914-450-2399
Mailing Address - Street 1:115 LAWTON ST APT 5H
Mailing Address - Street 2:
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10705-4636
Mailing Address - Country:US
Mailing Address - Phone:914-450-2399
Mailing Address - Fax:
Practice Address - Street 1:3250 WESTCHESTER AVE RM 108
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-4548
Practice Address - Country:US
Practice Address - Phone:718-597-5558
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THERACARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-03-02
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY72070938305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service