=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265562979
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EAST END KIDS THERAPY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2007
-----------------------------------------------------
Last Update Date | 04/10/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 502 N SEA RD
-----------------------------------------------------
City | SOUTHAMPTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11968-2012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-267-2900
-----------------------------------------------------
Fax | 631-267-2950
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 502 N SEA RD
-----------------------------------------------------
City | SOUTHAMPTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11968-2012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-267-2900
-----------------------------------------------------
Fax | 631-267-2950
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | DR. STEPHEN PETER SICILIAN
-----------------------------------------------------
Credential | PSYCHOLOGIST
-----------------------------------------------------
Telephone | 631-267-2900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------