Provider Demographics
NPI:1518441716
Name:LUCIEN, JEAN GARDY M
Entity type:Individual
Prefix:
First Name:JEAN GARDY
Middle Name:M
Last Name:LUCIEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:173 EASTWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11729-2201
Mailing Address - Country:US
Mailing Address - Phone:917-224-8336
Mailing Address - Fax:
Practice Address - Street 1:320 CARLETON AVE
Practice Address - Street 2:
Practice Address - City:CENTRAL ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11722-4506
Practice Address - Country:US
Practice Address - Phone:631-663-4300
Practice Address - Fax:631-439-4066
Is Sole Proprietor?:No
Enumeration Date:2018-09-24
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1964Medicaid
NY1975Medicaid