Healthcare Provider Details

I. General information

NPI: 1770850281
Provider Name (Legal Business Name): LIFELONG THERAPEUTICS OT PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2011
Last Update Date: 02/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 BEVERLY RD
HUNTINGTON STATION NY
11746-4522
US

IV. Provider business mailing address

143 CHARDONNAY DR
EAST QUOGUE NY
11942-3829
US

V. Phone/Fax

Practice location:
  • Phone: 631-278-0665
  • Fax: 631-549-1957
Mailing address:
  • Phone: 631-278-0665
  • Fax: 631-549-1957

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number006369
License Number StateNY

VIII. Authorized Official

Name: MR. JEFFREY WAYNE CIOLINO
Title or Position: PRESIDENT
Credential: OTR/L
Phone: 631-278-0665