=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275853293
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IAN D. LITHGOW LMFT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2010
-----------------------------------------------------
Last Update Date | 05/11/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 40 EXCHANGE PL FL 3
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10005-2784
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-912-5004
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 128 ATLANTIC AVE
-----------------------------------------------------
City | LONG BEACH
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11561-3805
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-912-5004
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 000804
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------