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General NPI Number Information
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NPI Number | 1427238005
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Entity Type | Organization
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Legal Business Name | THE FAMILY TREE PSYCHIATRIC & MEDICAL SERVICES
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Dates
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Enumeration Date | 11/12/2007
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Last Update Date | 11/12/2007
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Provider Practice Location Address
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Address Line | 5225 NESCONSET HWY STE 46
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City | PORT JEFFERSON STATION
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State | NY
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Zip | 11776-2060
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Country | US
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Telephone | 631-209-1477
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Fax | 631-744-3246
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Provider Business Mailing Address
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Address Line | 70 COBBLESTONE DR
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City | SHOREHAM
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State | NY
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Zip | 11786-2359
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Country | US
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Telephone | 631-209-1477
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Fax | 631-744-3246
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. ROBERT DANIEL COLUCCI
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Credential | D.O.
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Telephone | 631-209-1477
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 199981
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License Number State | NY
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