Provider Demographics
NPI:1871977009
Name:PSC COMMUNITY SUPPORT SERVICES, INC.
Entity type:Organization
Organization Name:PSC COMMUNITY SUPPORT SERVICES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:H
Authorized Official - Last Name:OLECHOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-349-1905
Mailing Address - Street 1:5102 21ST ST
Mailing Address - Street 2:FOURTH FLOOR - 4-A
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11101-5357
Mailing Address - Country:US
Mailing Address - Phone:718-349-1905
Mailing Address - Fax:718-349-0908
Practice Address - Street 1:5102 21ST ST
Practice Address - Street 2:FOURTH FLOOR - 4-A
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101-5357
Practice Address - Country:US
Practice Address - Phone:718-349-1905
Practice Address - Fax:718-349-0908
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PSC COMMUNITY SERVICES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-07-17
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1997L001302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02891821Medicaid
NY00926090Medicaid