1942882246 NPI number — SOUTH SHORE COLLABORATIVE PSYCHIATRY NP PLLC

Table of content: (NPI 1942882246)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942882246 NPI number — SOUTH SHORE COLLABORATIVE PSYCHIATRY NP PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH SHORE COLLABORATIVE PSYCHIATRY NP PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
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Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
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Provider Other Credential Text:
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NPI Number Information

NPI Number:
1942882246
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/26/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
128 CARLETON AVE STE 3
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAST ISLIP
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11730-1804
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-317-9480
Provider Business Mailing Address Fax Number:
631-277-6039

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
128 CARLETON AVE STE 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST ISLIP
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11730-1804
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-317-9480
Provider Business Practice Location Address Fax Number:
631-277-6039
Provider Enumeration Date:
04/26/2021

Additional Information

Authorized Official

Authorized Official Last Name:
ROCHE
Authorized Official First Name:
SAMANTHA
Authorized Official Middle Name:
Authorized Official Title or Position:
PMHNP-BC
Authorized Official Telephone Number:
631-317-9480

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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