Basic Information
| Provider Information | |||||||||
| NPI: | 1689758955 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JEWISH BOARD OF FAMILY AND CHILDREN SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PRIDE OF JUDEA | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 43-06 159TH STREET, | ||||||||
| Address2: | B4 | ||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184236200 | ||||||||
| FaxNumber: | 7184239762 | ||||||||
| Practice Location | |||||||||
| Address1: | JEWISH BOARD AND CHILDREN AND FAMILY SERVICES | ||||||||
| Address2: | PRIDE OF JUDEA COMMUNITY SERVICES (CLINIC) | ||||||||
| City: | DOUGLASTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184236200 | ||||||||
| FaxNumber: | 7184239762 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GELLIS | ||||||||
| AuthorizedOfficialFirstName: | DEBORAH | ||||||||
| AuthorizedOfficialMiddleName: | SUE | ||||||||
| AuthorizedOfficialTitleorPosition: | LICENCED CLINICAL SOCIAL WORKER | ||||||||
| AuthorizedOfficialTelephone: | 7189613521 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LCSW | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251T00000X | 071-000-1 | NY | Y | Agencies | PACE Provider Organization |
No ID Information.