Provider Demographics
NPI:1326284159
Name:LI ANXIETY CARE
Entity Type:Organization
Organization Name:LI ANXIETY CARE
Other - Org Name:LONG ISLAND AC & R GROUP LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:FUTTERSAK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:631-509-0601
Mailing Address - Street 1:55 NESCONSET HWY
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-2631
Mailing Address - Country:US
Mailing Address - Phone:631-509-0601
Mailing Address - Fax:631-509-0601
Practice Address - Street 1:55 NESCONSET HWY
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-2631
Practice Address - Country:US
Practice Address - Phone:631-509-0601
Practice Address - Fax:631-509-0601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-29
Last Update Date:2009-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010017103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV834Y1Medicare PIN