Provider Demographics
NPI:1770850281
Name:LIFELONG THERAPEUTICS OT PLLC
Entity Type:Organization
Organization Name:LIFELONG THERAPEUTICS OT PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:CIOLINO
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:631-278-0665
Mailing Address - Street 1:143 CHARDONNAY DR
Mailing Address - Street 2:
Mailing Address - City:EAST QUOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11942-3829
Mailing Address - Country:US
Mailing Address - Phone:631-278-0665
Mailing Address - Fax:631-549-1957
Practice Address - Street 1:165 BEVERLY RD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON STATION
Practice Address - State:NY
Practice Address - Zip Code:11746-4522
Practice Address - Country:US
Practice Address - Phone:631-278-0665
Practice Address - Fax:631-549-1957
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-28
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006369225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ95682Medicare PIN
NYQ0W6X1Medicare PIN