=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306412077
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIC MARRIAGE AND FAMILY THERAPY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2021
-----------------------------------------------------
Last Update Date | 07/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3164 21ST ST # 121
-----------------------------------------------------
City | LONG ISLAND CITY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11106-4573
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-365-9350
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3164 21ST ST # 121
-----------------------------------------------------
City | LONG ISLAND CITY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11106-4573
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-365-9350
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MARRIAGE AND FAMILY THERAPIST
-----------------------------------------------------
Name | MS. JENNIFER DISOMMA
-----------------------------------------------------
Credential | LICENSED
-----------------------------------------------------
Telephone | 631-365-9350
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------