Provider Demographics
NPI:1770141608
Name:SG LISENCED BEHAVIOR ANALYST PC
Entity type:Organization
Organization Name:SG LISENCED BEHAVIOR ANALYST PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SVETLANA
Authorized Official - Middle Name:
Authorized Official - Last Name:GLUZMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-254-9292
Mailing Address - Street 1:1830 E 31ST ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-4440
Mailing Address - Country:US
Mailing Address - Phone:917-254-9292
Mailing Address - Fax:
Practice Address - Street 1:31 QUADS WAY
Practice Address - Street 2:
Practice Address - City:WINDHAM
Practice Address - State:NY
Practice Address - Zip Code:12496-5323
Practice Address - Country:US
Practice Address - Phone:917-254-9292
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-05
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty