Provider Demographics
NPI:1427238005
Name:THE FAMILY TREE PSYCHIATRIC & MEDICAL SERVICES
Entity type:Organization
Organization Name:THE FAMILY TREE PSYCHIATRIC & MEDICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:COLUCCI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:631-209-1477
Mailing Address - Street 1:70 COBBLESTONE DR
Mailing Address - Street 2:
Mailing Address - City:SHOREHAM
Mailing Address - State:NY
Mailing Address - Zip Code:11786-2359
Mailing Address - Country:US
Mailing Address - Phone:631-209-1477
Mailing Address - Fax:631-744-3246
Practice Address - Street 1:5225 NESCONSET HWY STE 46
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-2060
Practice Address - Country:US
Practice Address - Phone:631-209-1477
Practice Address - Fax:631-744-3246
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-12
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1999812084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02916365Medicaid