Basic Information
Provider Information | |||||||||
NPI: | 1518441716 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LUCIEN | ||||||||
FirstName: | JEAN GARDY | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 173 EASTWOOD AVE | ||||||||
Address2: |   | ||||||||
City: | DEER PARK | ||||||||
State: | NY | ||||||||
PostalCode: | 117292201 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9172248336 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 320 CARLETON AVE | ||||||||
Address2: |   | ||||||||
City: | CENTRAL ISLIP | ||||||||
State: | NY | ||||||||
PostalCode: | 117224506 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6316634300 | ||||||||
FaxNumber: | 6314394066 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/24/2018 | ||||||||
LastUpdateDate: | 09/24/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X |   |   | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
ID | Type | State | Issuer | Description | 1964 | 05 | NY |   | MEDICAID | 1975 | 05 | NY |   | MEDICAID |