NPIMap

Organization Active NPI

Eating Disorder Treatment of New York, LLC

Doing business as Clementine North Shore

  • Adolescent and Children Mental Health Clinic/Center
  • Northport, NY
National Provider Identifier
1699528950
Registry record updated Jun 5, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Adolescent and Children Mental Health Clinic/CenterTaxonomy code 261QM0855X
Legal business name
EATING DISORDER TREATMENT OF NEW YORK, LLC
Doing business as
Clementine North Shore
Practice address
254 Bread and Cheese Hollow Rd
Northport, NY 11768-2606
Phone
(631) 540-0980
Fax
(631) 967-1667
NPI assigned
Apr 8, 2024
Last updated
Jun 5, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 5, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Jason Schulz
Title
Chief Financial Officer
Phone
(720) 440-4277

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Adolescent and Children Mental Health Clinic/Center 261QM0855X Primary

Addresses

Primary practice location

254 Bread and Cheese Hollow Rd
Northport, NY 11768-2606

Mailing address

6100 SW 76TH St
South Miami, FL 33143-5002
Phone (305) 663-1876

Other names 1

  • Clementine North Shore Doing business as

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
33D2305894Clementine North Shore254 Bread and Cheese Hollow Rd, Northport, NY 11768Certificate of waiverMar 26, 2027

National Provider Directory

National Provider Directory
Tax ID family
Eating Disorder Treatment of New York LLC10 organizations share this tax ID, including this one

Other organizations with this tax ID 9

Organizations that report the same tax identification number in the National Provider Directory.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1712534400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1749081600000",
    "number": "1699528950",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6100 SW 76TH ST",
            "city": "SOUTH MIAMI",
            "state": "FL",
            "postal_code": "331435002",
            "telephone_number": "305-663-1876",
            "fax_number": "786-359-4485"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "254 BREAD AND CHEESE HOLLOW RD",
            "city": "NORTHPORT",
            "state": "NY",
            "postal_code": "117682606",
            "telephone_number": "631-540-0980",
            "fax_number": "631-967-1667"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EATING DISORDER TREATMENT OF NEW YORK, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2024-04-08",
        "last_updated": "2025-06-05",
        "certification_date": "2025-06-05",
        "status": "A",
        "authorized_official_last_name": "SCHULZ",
        "authorized_official_first_name": "JASON",
        "authorized_official_title_or_position": "CHIEF FINANCIAL OFFICER",
        "authorized_official_telephone_number": "720-440-4277"
    },
    "taxonomies": [
        {
            "code": "261QM0855X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Adolescent and Children Mental Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Clementine North Shore",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Clementine North Shore",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Northport, NY

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 5, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.