MEDICARE: THERAPEUTIC WELLNESS LICENSED MENTAL HEALTH COUNSELING PC

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1447030333
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THERAPEUTIC WELLNESS LICENSED MENTAL HEALTH COUNSELING PC

Provider Business Mailing Address
First Line	:	443 HUDSON AVE
Second Line	:
City	:	MECHANICVILLE
State	:	NY
Zip	:	12118-4503
Country	:	US
Telephone Number	:	516-930-3571
Fax Number	:

Provider Business Practice Location Address
First Line	:	443 HUDSON AVE
Second Line	:
City	:	MECHANICVILLE
State	:	NY
Zip	:	12118-4503
Country	:	US
Telephone Number	:	516-930-3571
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JEFF D MCKENZIE
Credential	:	LMHC
Telephone Number	:	518-506-7880

Provider Enumeration Date	:	09/29/2023
Last Update Date	:	10/05/2023

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