Provider Demographics
NPI:1982185278
Name:JOSEPH, EDDY
Entity Type:Individual
Prefix:
First Name:EDDY
Middle Name:
Last Name:JOSEPH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1197
Mailing Address - Street 2:
Mailing Address - City:PEARL RIVER
Mailing Address - State:NY
Mailing Address - Zip Code:10965-0597
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:282 N. MIDDLETOWN RD
Practice Address - Street 2:
Practice Address - City:PEARL RIVER
Practice Address - State:NY
Practice Address - Zip Code:10965-1096
Practice Address - Country:US
Practice Address - Phone:833-334-3254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-24
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
NY103317-01103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY106S00000XMedicaid