Healthcare Provider Details

I. General information

NPI: 1366890949
Provider Name (Legal Business Name): SOUTH SHORE MENTAL HEALTH COUNSELING SERVICES,PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2016
Last Update Date: 04/25/2021
Certification Date: 04/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 CARLETON AVE STE D
EAST ISLIP NY
11730-1222
US

IV. Provider business mailing address

200 CARLETON AVE STE D
EAST ISLIP NY
11730-1222
US

V. Phone/Fax

Practice location:
  • Phone: 631-579-3503
  • Fax: 631-446-1136
Mailing address:
  • Phone: 631-579-3503
  • Fax: 631-446-1136

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number004685
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: KENNETH J ROCHE
Title or Position: DIRECTOR
Credential:
Phone: 631-235-4481