Provider Demographics
NPI:1295878577
Name:LONG ISLAND CONSULTATION CENTER, INC.
Entity type:Organization
Organization Name:LONG ISLAND CONSULTATION CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ELAINE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEDERER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:718-896-3400
Mailing Address - Street 1:9131 QUEENS BLVD STE 222
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-5511
Mailing Address - Country:US
Mailing Address - Phone:718-896-3400
Mailing Address - Fax:718-459-5621
Practice Address - Street 1:9131 QUEENS BLVD STE 222
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-5511
Practice Address - Country:US
Practice Address - Phone:718-896-3400
Practice Address - Fax:718-459-5621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY090210852101YA0400X
NY6715100A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00244019Medicaid