Healthcare Provider Details

I. General information

NPI: 1912602210
Provider Name (Legal Business Name): COURTNEY PLANK LCSW PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2023
Last Update Date: 04/04/2023
Certification Date: 04/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 BEDFORD BANKSVILLE RD
BEDFORD NY
10506-1918
US

IV. Provider business mailing address

209 BEDFORD BANKSVILLE RD
BEDFORD NY
10506-1918
US

V. Phone/Fax

Practice location:
  • Phone: 617-697-9471
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. COURTNEY PLANK RAULT
Title or Position: CEO
Credential: LCSW
Phone: 617-697-9471