Provider Demographics
NPI:1144665340
Name:BROOKHAVEN FAMILY MEDICINE
Entity type:Organization
Organization Name:BROOKHAVEN FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:MILLEISEN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-R
Authorized Official - Phone:631-447-3036
Mailing Address - Street 1:101 HOSPITAL ROAD
Mailing Address - Street 2:
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772
Mailing Address - Country:US
Mailing Address - Phone:631-447-3036
Mailing Address - Fax:631-447-3053
Practice Address - Street 1:100 HOSPITAL ROAD
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772
Practice Address - Country:US
Practice Address - Phone:631-687-6900
Practice Address - Fax:631-447-5954
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BROOKHAVEN FAMILY MEDICINE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-05-02
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center