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General NPI Number Information
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NPI Number | 1558139709
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Entity Type | Organization
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Legal Business Name | SELF INITIATED LIVING OPTIONS INC
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Dates
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Enumeration Date | 12/18/2023
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Last Update Date | 12/18/2023
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Provider Practice Location Address
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Address Line | 3245 ROUTE 112 STE 1
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City | MEDFORD
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State | NY
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Zip | 11763-1441
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Country | US
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Telephone | 631-880-7929
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Fax |
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Provider Business Mailing Address
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Address Line | 3253 ROUTE 112 BLDG 10
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City | MEDFORD
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State | NY
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Zip | 11763-1411
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Country | US
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Telephone | 631-880-7329
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Fax |
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Authorized Official
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Title or Position | AM
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Name | LAURIE DELGADO
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Credential |
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Telephone | 631-880-7929
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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