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General NPI Number Information
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NPI Number | 1033581517
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Entity Type | Organization
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Legal Business Name | PEDERSON-KRAG CENTER
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Dates
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Enumeration Date | 10/23/2015
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Last Update Date | 10/23/2015
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Provider Practice Location Address
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Address Line | 8 CHESTER CT
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City | HUNTINGTON
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State | NY
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Zip | 11743-5834
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Country | US
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Telephone | 631-754-1684
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Fax |
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Provider Business Mailing Address
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Address Line | 8 CHESTER CT
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City | HUNTINGTON
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State | NY
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Zip | 11743-5834
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Country | US
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Telephone | 631-754-1684
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Fax |
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Authorized Official
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Title or Position | PSYCHOLOGIST
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Name | DR. MAX BANILIVY
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Credential |
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Telephone | 631-920-8164
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 41309
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License Number State | NY
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