Provider Demographics
NPI:1043869464
Name:PRIVATE PRACTICE PSYCHIATRY SERVICES LLC
Entity Type:Organization
Organization Name:PRIVATE PRACTICE PSYCHIATRY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COUNSELOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:PETRY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-R
Authorized Official - Phone:631-392-4357
Mailing Address - Street 1:67 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-2422
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:631-392-4358
Practice Address - Street 1:67 E MAIN ST
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2422
Practice Address - Country:US
Practice Address - Phone:631-392-4357
Practice Address - Fax:631-392-4358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-09
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1497856108OtherCOMMERICAL