Provider Demographics
NPI:1053938837
Name:ACTIVE CHANGE PSYCHOLOGICAL SERVICES, PLLC
Entity type:Organization
Organization Name:ACTIVE CHANGE PSYCHOLOGICAL SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JAY
Authorized Official - Middle Name:EVAN
Authorized Official - Last Name:SAUL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:516-835-2048
Mailing Address - Street 1:6800 JERICHO TPKE STE 120W
Mailing Address - Street 2:
Mailing Address - City:SYOSSET
Mailing Address - State:NY
Mailing Address - Zip Code:11791-4445
Mailing Address - Country:US
Mailing Address - Phone:516-835-2048
Mailing Address - Fax:
Practice Address - Street 1:6800 JERICHO TPKE STE 120W
Practice Address - Street 2:
Practice Address - City:SYOSSET
Practice Address - State:NY
Practice Address - Zip Code:11791-4445
Practice Address - Country:US
Practice Address - Phone:516-835-2048
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-29
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty