Provider Demographics
NPI:1497251995
Name:FAMILY SERVICE LEAGUE
Entity Type:Organization
Organization Name:FAMILY SERVICE LEAGUE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF REVENUE CYCLE MANAGEMEN
Authorized Official - Prefix:
Authorized Official - First Name:CRISTIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-647-3100
Mailing Address - Street 1:1444 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-4147
Mailing Address - Country:US
Mailing Address - Phone:631-647-3100
Mailing Address - Fax:631-647-2058
Practice Address - Street 1:1444 FIFTH AVE
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706
Practice Address - Country:US
Practice Address - Phone:631-647-3100
Practice Address - Fax:631-647-2058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-03
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY099472251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY111631827Medicaid