Healthcare Provider Details

I. General information

NPI: 1558139709
Provider Name (Legal Business Name): SELF INITIATED LIVING OPTIONS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2023
Last Update Date: 12/18/2023
Certification Date: 12/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3245 ROUTE 112 STE 1
MEDFORD NY
11763-1441
US

IV. Provider business mailing address

3253 ROUTE 112 BLDG 10
MEDFORD NY
11763-1411
US

V. Phone/Fax

Practice location:
  • Phone: 631-880-7929
  • Fax:
Mailing address:
  • Phone: 631-880-7329
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: LAURIE DELGADO
Title or Position: AM
Credential:
Phone: 631-880-7929