Healthcare Provider Details

I. General information

NPI: 1134751696
Provider Name (Legal Business Name): BLUE SEA FAMILY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2020
Last Update Date: 02/13/2020
Certification Date: 02/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 FENIMORE LN
HUNTINGTON NY
11743-5720
US

IV. Provider business mailing address

25 FENIMORE LN
HUNTINGTON NY
11743-5720
US

V. Phone/Fax

Practice location:
  • Phone: 631-368-2583
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State

VIII. Authorized Official

Name: AMANDA NARRA
Title or Position: BEHAVIOR ANALYST
Credential: LBA
Phone: 631-368-2583