Provider Demographics
NPI:1164594065
Name:FAMILY LIFE PSYCHOLOGICAL SERVICES PC
Entity Type:Organization
Organization Name:FAMILY LIFE PSYCHOLOGICAL SERVICES PC
Other - Org Name:DR HERBERT S COHEN
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HERBERT
Authorized Official - Middle Name:S
Authorized Official - Last Name:COHEN
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:203-968-0469
Mailing Address - Street 1:106 GUN CLUB ROAD
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06903-1024
Mailing Address - Country:US
Mailing Address - Phone:203-968-0469
Mailing Address - Fax:
Practice Address - Street 1:106 GUN CLUB ROAD
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06903-1024
Practice Address - Country:US
Practice Address - Phone:203-968-0469
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000918103T00000X
CT00145106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT060000918CT01OtherANTHEM BLUE CROSS BLUE SH