Provider Demographics
NPI:1598875692
Name:PORT JEFFERSON PSYCHOLOGICAL & VOCATIONAL P.C.
Entity Type:Organization
Organization Name:PORT JEFFERSON PSYCHOLOGICAL & VOCATIONAL P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:C
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:631-928-4635
Mailing Address - Street 1:5225-46 ROUTE 347
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-2060
Mailing Address - Country:US
Mailing Address - Phone:631-928-4635
Mailing Address - Fax:631-928-4784
Practice Address - Street 1:5225-46 ROUTE 347
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-2060
Practice Address - Country:US
Practice Address - Phone:631-928-4635
Practice Address - Fax:631-928-4784
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
144865OtherVALUE OPTIONS
NY02416457Medicaid
7333181002OtherGHI
211135000OtherMAGELLAN
NY02416457Medicaid