Provider Demographics
NPI:1235526443
Name:A DIFFERENT JOURNEY, LLC
Entity Type:Organization
Organization Name:A DIFFERENT JOURNEY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRIMARY THERAPIST-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:VIVIAN
Authorized Official - Middle Name:STANFORD
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSWR
Authorized Official - Phone:646-263-6227
Mailing Address - Street 1:134 MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE GROVE
Mailing Address - State:NY
Mailing Address - Zip Code:11755-2000
Mailing Address - Country:US
Mailing Address - Phone:646-263-6227
Mailing Address - Fax:
Practice Address - Street 1:26 COURT ST STE 1502
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11242-1115
Practice Address - Country:US
Practice Address - Phone:646-263-6227
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-26
Last Update Date:2015-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR059610-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty