Provider Demographics
NPI:1285169193
Name:SUPPORTIVE PSYCHOLOGICAL SERVICES OF LONG ISLAND, P.C.
Entity type:Organization
Organization Name:SUPPORTIVE PSYCHOLOGICAL SERVICES OF LONG ISLAND, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:GANZENMULLER
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:631-252-1221
Mailing Address - Street 1:PO BOX 1226
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-0900
Mailing Address - Country:US
Mailing Address - Phone:631-252-1221
Mailing Address - Fax:
Practice Address - Street 1:6500 JERICHO TPKE
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-2909
Practice Address - Country:US
Practice Address - Phone:631-252-1221
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-28
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty