Healthcare Provider Details

I. General information

NPI: 1376901926
Provider Name (Legal Business Name): TIJO THOMAS THAYIL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2016
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 SUNRISE HWY STE 200
LYNBROOK NY
11563-2950
US

IV. Provider business mailing address

184 BETTE RD
EAST MEADOW NY
11554-1305
US

V. Phone/Fax

Practice location:
  • Phone: 516-350-8564
  • Fax:
Mailing address:
  • Phone: 516-749-3342
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number015959
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: