Healthcare Provider Details

I. General information

NPI: 1588804587
Provider Name (Legal Business Name): AMERICAN THERAPY GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2009
Last Update Date: 03/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1840 UNION BLVD
BAY SHORE NY
11706-7932
US

IV. Provider business mailing address

1840 UNION BLVD
BAY SHORE NY
11706-7932
US

V. Phone/Fax

Practice location:
  • Phone: 631-647-7893
  • Fax:
Mailing address:
  • Phone: 631-647-7893
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number010404-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number025669
License Number StateNY

VIII. Authorized Official

Name: SHAFER ZYSMAN
Title or Position: MBR
Credential:
Phone: 631-647-7885