Healthcare Provider Details

I. General information

NPI: 1629982145
Provider Name (Legal Business Name): FORTITUDE LICENSED CLINICAL SOCIAL WORK PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2026
Last Update Date: 10/01/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 ORVILLE DR STE 100
BOHEMIA NY
11716-2505
US

IV. Provider business mailing address

80 ORVILLE DR STE 100
BOHEMIA NY
11716-2505
US

V. Phone/Fax

Practice location:
  • Phone: 419-581-9810
  • Fax:
Mailing address:
  • Phone: 419-581-9810
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. JOSEPH CONKLIN
Title or Position: MEMBER
Credential: LCSW, CASAC-ADVANCED
Phone: 419-581-9810