{
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"FirstLineMailingAddress": "1212 N COUNTRY RD STE 2A",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "STONY BROOK",
"MailingAddressStateName": "NY",
"MailingAddressPostalCode": "11790-1919",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "631-689-5155",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "1212 N COUNTRY RD STE 2A",
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"PracticeLocationAddressCityName": "STONY BROOK",
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"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "10/13/2006",
"LastUpdateDate": "09/11/2025",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "FAIREY",
"AuthorizedOfficialFirstName": "GEORGE",
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"AuthorizedOfficialCredential": "M.D.",
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"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "101YM0800X",
"TaxonomyName": "Mental Health Counselor",
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"LicenseNumberStateCode": "NY",
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},
{
"TaxonomyCode": "261QM0850X",
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}
]
},
"HealthcareProviderTaxonomyGroups": {
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"HealthcareProviderTaxonomyGroupName": "193400000X SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
}
}
}