Healthcare Provider Details

I. General information

NPI: 1598875692
Provider Name (Legal Business Name): PORT JEFFERSON PSYCHOLOGICAL & VOCATIONAL P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 02/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5225-46 ROUTE 347
PORT JEFFERSON STATION NY
11776-2060
US

IV. Provider business mailing address

5225-46 ROUTE 347
PORT JEFFERSON STATION NY
11776-2060
US

V. Phone/Fax

Practice location:
  • Phone: 631-928-4635
  • Fax: 631-928-4784
Mailing address:
  • Phone: 631-928-4635
  • Fax: 631-928-4784

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: SARAH C LONG
Title or Position: OWNER
Credential: PSY.D.
Phone: 631-928-4635