Healthcare Provider Details

I. General information

NPI: 1083827448
Provider Name (Legal Business Name): THERESA VALERIE EADS LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 03/31/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 SUNRISE HWY
AMITYVILLE NY
11701-2508
US

IV. Provider business mailing address

385 ONTARIO ST
RONKONKOMA NY
11779-4946
US

V. Phone/Fax

Practice location:
  • Phone: 631-608-5308
  • Fax: 631-608-5264
Mailing address:
  • Phone: 631-806-3186
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: