| Self Initiated Living Options Inc | |
|
3253 Route 112 Bldg 10 Medford NY 11763-1411 | |
| (631) 880-7929 | |
| (631) 946-6377 |
| Full Name | Self Initiated Living Options Inc |
|---|---|
| Speciality | Community/Behavioral Health |
| Location | 3253 Route 112 Bldg 10, Medford, New York |
| Authorized Official Name and Position | Joseph Delgado (CHIEF EXECUTIVE OFFICER) |
| Authorized Official Contact | 6318807929 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Self Initiated Living Options Inc 3253 Route 112 Bldg 10 Medford NY 11763-1411 Ph: (631) 880-7929 | Self Initiated Living Options Inc 3253 Route 112 Bldg 10 Medford NY 11763-1411 Ph: (631) 880-7929 |
| NPI Number | 1215501424 |
|---|---|
| Provider Enumeration Date | 05/13/2021 |
| Last Update Date | 08/24/2021 |
| Certification Date | 08/10/2021 |
| Medicare PECOS PAC ID | 0244617439 |
|---|---|
| Medicare Enrollment ID | O20220509001366 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1215501424 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 251S00000X | Community/behavioral Health | (* (Not Available)) | Primary |
| Provider Name | Marina Urazov |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1710949284 PECOS PAC ID: 7618128406 Enrollment ID: I20121102000197 |
| Provider Name | Susan M Trees |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1912219841 PECOS PAC ID: 3779835335 Enrollment ID: I20181009002042 |
| Provider Name | Kim Bjorklund |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1952784241 PECOS PAC ID: 6709275795 Enrollment ID: I20220602002032 |
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