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General NPI Number Information
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NPI Number | 1518256619
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Entity Type | Organization
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Legal Business Name | EAST END KIDS PSY, SLP, OT & PT SERV. PLLC
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Dates
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Enumeration Date | 03/30/2011
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Last Update Date | 03/30/2011
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Provider Practice Location Address
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Address Line | 502 N SEA RD
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City | SOUTHAMPTON
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State | NY
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Zip | 11968-2012
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Country | US
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Telephone | 631-267-2900
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Fax | 631-267-2950
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Provider Business Mailing Address
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Address Line | 502 N SEA RD
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City | SOUTHAMPTON
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State | NY
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Zip | 11968-2012
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Country | US
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Telephone | 631-267-2900
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Fax | 631-267-2950
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR / PSYCHOLOGIST
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Name | DR. STEPHEN SICILIAN
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Credential | PH.D.
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Telephone | 631-267-2900
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC1900X
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Taxonomy Name | Counseling Psychologist
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License Number | 009036
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License Number State | NY
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