Provider Demographics
NPI:1881998219
Name:JORDANCAMERONMOSESPLAYHOUSE
Entity type:Organization
Organization Name:JORDANCAMERONMOSESPLAYHOUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NELSON
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSES
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, CCC-SLP
Authorized Official - Phone:347-526-6812
Mailing Address - Street 1:118 OHIO AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11561-1130
Mailing Address - Country:US
Mailing Address - Phone:347-526-6812
Mailing Address - Fax:718-780-4007
Practice Address - Street 1:118 OHIO AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:NY
Practice Address - Zip Code:11561-1130
Practice Address - Country:US
Practice Address - Phone:347-526-6812
Practice Address - Fax:718-780-4007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-28
Last Update Date:2010-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001515235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJOR011000OtherNEW YORK CITY BOARD OF EDUCATION IDENTIFIER