Provider Demographics
NPI:1922134253
Name:WANTAGH PSYCHOLOGICAL COUNSELING SERVICES PC
Entity Type:Organization
Organization Name:WANTAGH PSYCHOLOGICAL COUNSELING SERVICES PC
Other - Org Name:WANTAGH SEAFORD COUNSELING SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:H
Authorized Official - Last Name:PERLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:516-781-0457
Mailing Address - Street 1:1926 OAKLAND AVE
Mailing Address - Street 2:
Mailing Address - City:WANTAGH
Mailing Address - State:NY
Mailing Address - Zip Code:11793-3610
Mailing Address - Country:US
Mailing Address - Phone:516-781-0457
Mailing Address - Fax:516-781-0457
Practice Address - Street 1:1926 OAKLAND AVE
Practice Address - Street 2:
Practice Address - City:WANTAGH
Practice Address - State:NY
Practice Address - Zip Code:11793-3610
Practice Address - Country:US
Practice Address - Phone:516-781-0457
Practice Address - Fax:516-781-0457
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2011-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY10383103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01281929Medicaid
NY01281929Medicaid