Healthcare Provider Details

I. General information

NPI: 1356422299
Provider Name (Legal Business Name): JOSEPH MICHAEL O'LEARY LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 08/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 OAK ST
COPIAGUE NY
11726-3111
US

IV. Provider business mailing address

172 AMSTERDAM AVE
WEST BABYLON NY
11704-4831
US

V. Phone/Fax

Practice location:
  • Phone: 631-691-7080
  • Fax: 631-692-3387
Mailing address:
  • Phone: 631-539-4103
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number073962
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: