Provider Demographics
NPI:1306412077
Name:LIC MARRIAGE AND FAMILY THERAPY PLLC
Entity Type:Organization
Organization Name:LIC MARRIAGE AND FAMILY THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MARRIAGE AND FAMILY THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:DISOMMA
Authorized Official - Suffix:
Authorized Official - Credentials:LICENSED
Authorized Official - Phone:631-365-9350
Mailing Address - Street 1:3164 21ST ST # 121
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11106-4573
Mailing Address - Country:US
Mailing Address - Phone:631-365-9350
Mailing Address - Fax:
Practice Address - Street 1:3164 21ST ST # 121
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11106-4573
Practice Address - Country:US
Practice Address - Phone:631-365-9350
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-02
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty