=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083256580
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | QUINN EDWARD FUNN II B.A, M.A
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/16/2019
-----------------------------------------------------
Last Update Date | 10/16/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 83 E MAIN ST
-----------------------------------------------------
City | BAY SHORE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11706-8305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-830-7810
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 32 WOODED WAY
-----------------------------------------------------
City | CALVERTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11933-9706
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC1900X
-----------------------------------------------------
Taxonomy Name | Counseling Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------