Provider Demographics
NPI:1497154298
Name:INTENTIONAL LIVING PSYCHOLOGICAL SERVICES, PLLC
Entity Type:Organization
Organization Name:INTENTIONAL LIVING PSYCHOLOGICAL SERVICES, PLLC
Other - Org Name:INTENTIONAL LIVING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR/PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:TERRACCIANO
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:646-478-7682
Mailing Address - Street 1:875 SIXTH AVENUE
Mailing Address - Street 2:SUITE 1603
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001-3574
Mailing Address - Country:US
Mailing Address - Phone:646-478-7682
Mailing Address - Fax:
Practice Address - Street 1:875 SIXTH AVENUE
Practice Address - Street 2:SUITE 1603
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-3574
Practice Address - Country:US
Practice Address - Phone:646-478-7682
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-18
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015554103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Single Specialty