Provider Demographics
NPI:1265482491
Name:SENIOR CONNECTIONS PSYCHOLOGICAL SE
Entity Type:Organization
Organization Name:SENIOR CONNECTIONS PSYCHOLOGICAL SE
Other - Org Name:SENIOR CONNECTIONS PSYCHOLOGICAL SERVICES OF NEW YORK PC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:DANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:845-781-6061
Mailing Address - Street 1:P.O. BOX 130926
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77393-0926
Mailing Address - Country:US
Mailing Address - Phone:281-292-1897
Mailing Address - Fax:281-292-1787
Practice Address - Street 1:270 RIVERSIDE DR.
Practice Address - Street 2:#201
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790
Practice Address - Country:US
Practice Address - Phone:845-781-6061
Practice Address - Fax:607-729-0757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02668179Medicaid
NYDD5776OtherRAILROAD MEDICARE
NYDD5776OtherRAILROAD MEDICARE
NYBA0383Medicare PIN