Provider Demographics
NPI:1881152932
Name:CARL DAVID RICHARDSON FOUNDATION, INC.
Entity type:Organization
Organization Name:CARL DAVID RICHARDSON FOUNDATION, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOHANN
Authorized Official - Middle Name:ANDRIA
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-313-7591
Mailing Address - Street 1:14556 229TH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11413-3923
Mailing Address - Country:US
Mailing Address - Phone:800-313-7591
Mailing Address - Fax:718-949-6315
Practice Address - Street 1:14556 229TH ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11413-3923
Practice Address - Country:US
Practice Address - Phone:800-313-7591
Practice Address - Fax:718-949-6315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-07
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY45-86-41Medicaid
NY1770839011Medicaid