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General NPI Number Information
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NPI Number | 1558979377
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Entity Type | Organization
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Legal Business Name | SOUTH SHORE PSYCHIATRIC NURSE PRACTITIONER GROUP
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Dates
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Enumeration Date | 07/17/2020
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Last Update Date | 07/21/2020
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Provider Practice Location Address
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Address Line | 245 W MAIN ST
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City | BAY SHORE
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State | NY
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Zip | 11706-8323
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Country | US
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Telephone | 631-771-7555
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Fax |
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Provider Business Mailing Address
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Address Line | 154 CHICHESTER AVE
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City | CENTER MORICHES
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State | NY
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Zip | 11934-2004
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Country | US
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Telephone | 631-400-9251
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Fax | 516-447-3403
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Authorized Official
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Title or Position | OFFICE MGR
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Name | TENNILLE BRAITHWAITE
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Credential |
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Telephone | 631-400-9251
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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