Healthcare Provider Details

I. General information

NPI: 1932265683
Provider Name (Legal Business Name): BUTTERFLY CLINICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 08/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 MAIN ST
BAYSHORE NY
11706
US

IV. Provider business mailing address

250 MAIN ST
BAYSHORE NY
11706
US

V. Phone/Fax

Practice location:
  • Phone: 631-666-1951
  • Fax:
Mailing address:
  • Phone: 631-666-1951
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. JEAN BACON
Title or Position: OWNER
Credential: PHD,LCSW-R
Phone: 631-666-1951