=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336723261
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VICTIMS INFORMATION BUREAU OF SUFFOLK
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/06/2021
-----------------------------------------------------
Last Update Date | 05/06/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 185 OVAL DR
-----------------------------------------------------
City | ISLANDIA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11749-1402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-360-3730
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 185 OVAL DR
-----------------------------------------------------
City | ISLANDIA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11749-1402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-360-3730
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF DEVELOPMENT
-----------------------------------------------------
Name | HEATHER PARROTT
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 631-360-3930
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------