Provider Demographics
NPI:1346680071
Name:BEHAVIORAL ENHANCEMENT & SUBSTANCE ABUSE MEDICINE TREATMENT PLLC
Entity Type:Organization
Organization Name:BEHAVIORAL ENHANCEMENT & SUBSTANCE ABUSE MEDICINE TREATMENT PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM SUPERVISOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:M
Authorized Official - Last Name:PETRY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, CASAC
Authorized Official - Phone:631-392-4357
Mailing Address - Street 1:770 GRAND BLVD
Mailing Address - Street 2:SUITE 17
Mailing Address - City:DEER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11729-5750
Mailing Address - Country:US
Mailing Address - Phone:631-392-4357
Mailing Address - Fax:631-392-4358
Practice Address - Street 1:770 GRAND BLVD
Practice Address - Street 2:SUITE 17
Practice Address - City:DEER PARK
Practice Address - State:NY
Practice Address - Zip Code:11729-5750
Practice Address - Country:US
Practice Address - Phone:631-392-4357
Practice Address - Fax:631-392-4358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-26
Last Update Date:2013-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY140511797251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY140511797OtherOASAS