{
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"EIN": null,
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"OtherCredential": "LMFT",
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"FirstLineMailingAddress": "PO BOX 505",
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"MailingAddressCityName": "KINGS PARK",
"MailingAddressStateName": "NY",
"MailingAddressPostalCode": "11754-0505",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "631-656-0563",
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"FirstLinePracticeLocationAddress": "103 FORT SALONGA RD STE 14",
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"PracticeLocationAddressCityName": "NORTHPORT",
"PracticeLocationAddressStateName": "NY",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "631-656-0563",
"PracticeLocationAddressFaxNumber": "631-651-8688",
"EnumerationDate": "01/08/2007",
"LastUpdateDate": "11/27/2024",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "F",
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"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": null,
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "106H00000X",
"TaxonomyName": "Marriage & Family Therapist",
"LicenseNumber": "000002-1",
"LicenseNumberStateCode": "NY",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}