Healthcare Provider Details

I. General information

NPI: 1780071134
Provider Name (Legal Business Name): FAMILY PRESERVATION SERVICES OF LONG ISLAND,INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2015
Last Update Date: 04/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

732 GLOVER PL
BALDWIN NY
11510-3505
US

IV. Provider business mailing address

732 GLOVER PL
BALDWIN NY
11510-3505
US

V. Phone/Fax

Practice location:
  • Phone: 516-546-0102
  • Fax: 516-546-2684
Mailing address:
  • Phone: 516-546-0102
  • Fax: 516-546-2684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License NumberR045230-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License NumberR045230-1
License Number StateNY

VIII. Authorized Official

Name: PROF. FERN DEBRA SIMON
Title or Position: EXECUTIVE DIRECTOR
Credential: LCSWR
Phone: 516-546-0102