MEDICARE: SAFE SHORE THERAPY LCSW, PLLC

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

General Provider Information

NPI Number	:	1922965748
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAFE SHORE THERAPY LCSW, PLLC

Provider Business Mailing Address
First Line	:	244 E MAIN ST STE 119
Second Line	:
City	:	EAST ISLIP
State	:	NY
Zip	:	11730-2712
Country	:	US
Telephone Number	:	631-319-0106
Fax Number	:

Provider Business Practice Location Address
First Line	:	68 JOHNSON LN
Second Line	:
City	:	BAY SHORE
State	:	NY
Zip	:	11706-7813
Country	:	US
Telephone Number	:	631-319-0106
Fax Number	:

Authorized Official
Title or Position	:	MEMBER-MANAGER
Name	:	NICHOLAS EDWARD SIEBAN
Credential	:	LCSW
Telephone Number	:	631-319-0106

Provider Enumeration Date	:	01/05/2026
Last Update Date	:	01/05/2026

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