Provider Demographics
NPI:1427424530
Name:DANCING GODDESS RISING MINISTRIES, LLC
Entity type:Organization
Organization Name:DANCING GODDESS RISING MINISTRIES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JERRA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:JULIANO
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:516-426-2700
Mailing Address - Street 1:21 E 2ND STREET
Mailing Address - Street 2:SUITE 101
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901
Mailing Address - Country:US
Mailing Address - Phone:516-426-2700
Mailing Address - Fax:
Practice Address - Street 1:21 E 2ND ST
Practice Address - Street 2:SUITE 101
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-4616
Practice Address - Country:US
Practice Address - Phone:516-426-2700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-12
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0829261251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health