Provider Demographics
NPI:1750863494
Name:SELIGSON, BROOKE DANIELLE
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:DANIELLE
Last Name:SELIGSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3295 NEPTUNE AVE
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11572-4343
Mailing Address - Country:US
Mailing Address - Phone:516-849-0693
Mailing Address - Fax:
Practice Address - Street 1:229 LAUREL RD
Practice Address - Street 2:
Practice Address - City:EAST NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11731-1100
Practice Address - Country:US
Practice Address - Phone:631-659-3337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-29
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY842930141106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician