Basic Information
| Provider Information | |||||||||
| NPI: | 1467702761 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NYLIC | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | LAUREN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HEALY | ||||||||
| OtherFirstName: | MELISSA | ||||||||
| OtherMiddleName: | LAUREN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 36 NASSAU AVENUE | ||||||||
| Address2: | |||||||||
| City: | GLEN COVE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166501851 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 189 WHEATLEY ROAD | ||||||||
| Address2: | |||||||||
| City: | BROOKVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166261000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2012 | ||||||||
| LastUpdateDate: | 09/13/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TS0200X | 1149323 | NY | Y | Behavioral Health & Social Service Providers | Psychologist | School |
No ID Information.