Provider Demographics
NPI:1124399928
Name:UNITED SUPPORTS FOR AUTISM
Entity Type:Organization
Organization Name:UNITED SUPPORTS FOR AUTISM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:GOLDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:516-848-8551
Mailing Address - Street 1:283 COMMACK RD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-6021
Mailing Address - Country:US
Mailing Address - Phone:516-848-8551
Mailing Address - Fax:
Practice Address - Street 1:283 COMMACK RD.
Practice Address - Street 2:SUITE 205
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-6021
Practice Address - Country:US
Practice Address - Phone:516-848-8551
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-25
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017826251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health