Basic Information
| Provider Information | |||||||||
| NPI: | 1306210125 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IFE LANDSMARK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 260 MONTAUK HWY | ||||||||
| Address2: | SUITE 8 | ||||||||
| City: | BAY SHORE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117068322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6316479011 | ||||||||
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| Practice Location | |||||||||
| Address1: | NEW BROADVIEW MANOR - 70 FATHER CAPODANNO BLVD | ||||||||
| Address2: | |||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182738900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2015 | ||||||||
| LastUpdateDate: | 11/17/2015 | ||||||||
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| AuthorizedOfficialLastName: | FALES | ||||||||
| AuthorizedOfficialFirstName: | JAMIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6316479011 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 008096-1 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.