=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164594065
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY LIFE PSYCHOLOGICAL SERVICES PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2006
-----------------------------------------------------
Last Update Date | 09/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 106 GUN CLUB ROAD
-----------------------------------------------------
City | STAMFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06903-1024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-968-0469
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 106 GUN CLUB ROAD
-----------------------------------------------------
City | STAMFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06903-1024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-968-0469
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. HERBERT S COHEN
-----------------------------------------------------
Credential | EDD
-----------------------------------------------------
Telephone | 203-968-0469
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 000918
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 00145
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------