=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548876790
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EXPRESSIVE CONNECTIONS MENTAL HEALTH COUNSELING, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2020
-----------------------------------------------------
Last Update Date | 01/03/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 211 BROADWAY
-----------------------------------------------------
City | LYNBROOK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11563-3290
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-619-6477
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 63 LOUDEN AVE
-----------------------------------------------------
City | AMITYVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11701-2736
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-650-4164
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | CHRISTINA DIBERNARDO
-----------------------------------------------------
Credential | LMHC, BCB
-----------------------------------------------------
Telephone | 516-650-4164
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------