MEDICARE: LONG ISLAND PSYCHOTHERAPY & COUNSELING, LCSW P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	063837	NY

General Provider Information

NPI Number	:	1134660624
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LONG ISLAND PSYCHOTHERAPY & COUNSELING, LCSW P.C.

Provider Business Mailing Address
First Line	:	8 DALTON LN
Second Line	:
City	:	EAST NORTHPORT
State	:	NY
Zip	:	11731-3909
Country	:	US
Telephone Number	:	347-772-8373
Fax Number	:

Provider Business Practice Location Address
First Line	:	97 POWERHOUSE RD STE 104
Second Line	:
City	:	ROSLYN HEIGHTS
State	:	NY
Zip	:	11577-2046
Country	:	US
Telephone Number	:	347-772-8373
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	PABLO IDEZ
Credential	:
Telephone Number	:	347-772-8373

Provider Enumeration Date	:	03/16/2017
Last Update Date	:	12/13/2020

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