Provider Demographics
NPI:1376288530
Name:SUNRISE PARK PSYCHOTHERAPY LCSW PC
Entity Type:Organization
Organization Name:SUNRISE PARK PSYCHOTHERAPY LCSW PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:GINA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:CUBILLOS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:516-644-6495
Mailing Address - Street 1:1228 WANTAGH AVE STE 111
Mailing Address - Street 2:
Mailing Address - City:WANTAGH
Mailing Address - State:NY
Mailing Address - Zip Code:11793-2209
Mailing Address - Country:US
Mailing Address - Phone:516-644-6495
Mailing Address - Fax:516-324-3143
Practice Address - Street 1:1228 WANTAGH AVE STE 111
Practice Address - Street 2:
Practice Address - City:WANTAGH
Practice Address - State:NY
Practice Address - Zip Code:11793-2209
Practice Address - Country:US
Practice Address - Phone:516-644-6495
Practice Address - Fax:516-324-3143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-02
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1048692OtherBEACON HEALTH OPTIONS
NYNKN592OtherBCBS ANTHEM ID