Basic Information
| Provider Information | |||||||||
| NPI: | 1265711840 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY SERVIVE LEAGUE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 75 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | RIVERHEAD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 119012422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6312842565 | ||||||||
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| Practice Location | |||||||||
| Address1: | 75 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | RIVERHEAD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 119012422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6312842565 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2011 | ||||||||
| LastUpdateDate: | 08/12/2011 | ||||||||
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| AuthorizedOfficialLastName: | MCGOWAN | ||||||||
| AuthorizedOfficialFirstName: | MICHELLE | ||||||||
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| AuthorizedOfficialTitleorPosition: | RN | ||||||||
| AuthorizedOfficialTelephone: | 6312842565 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 445998-1 | NY | Y | Agencies | Community/Behavioral Health |
No ID Information.