=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619907573
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DR. JOSEPH PERINO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/04/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 233 UNION AVE STE. 101
-----------------------------------------------------
City | HOLBROOK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11741-1820
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-689-9424
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 120
-----------------------------------------------------
City | EAST SETAUKET
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11733-0120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-689-9424
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 004608
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------