Provider Demographics
NPI:1982185161
Name:LIFESPAN WELLNESS MARRIAGE & FAMILY THERAPY PLLC
Entity Type:Organization
Organization Name:LIFESPAN WELLNESS MARRIAGE & FAMILY THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CONSTANTINOU
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:917-913-6441
Mailing Address - Street 1:2608 BAYSIDE LN
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11358-1054
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21333 39TH AVE STE 235
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-2174
Practice Address - Country:US
Practice Address - Phone:917-913-6441
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-24
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001372106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1730626896OtherNPPES