Provider Demographics
NPI:1780071134
Name:FAMILY PRESERVATION SERVICES OF LONG ISLAND,INC.
Entity type:Organization
Organization Name:FAMILY PRESERVATION SERVICES OF LONG ISLAND,INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:PROF
Authorized Official - First Name:FERN
Authorized Official - Middle Name:DEBRA
Authorized Official - Last Name:SIMON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSWR
Authorized Official - Phone:516-546-0102
Mailing Address - Street 1:732 GLOVER PL
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-3505
Mailing Address - Country:US
Mailing Address - Phone:516-546-0102
Mailing Address - Fax:516-546-2684
Practice Address - Street 1:732 GLOVER PL
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:NY
Practice Address - Zip Code:11510-3505
Practice Address - Country:US
Practice Address - Phone:516-546-0102
Practice Address - Fax:516-546-2684
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FERN SIMON,LCSWR
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-04-23
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR045230-1253Z00000X, 251V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable
No253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02123128Medicaid
NY02123128Medicaid