Healthcare Provider Details

I. General information

NPI: 1538089081
Provider Name (Legal Business Name): SOARING FEATHERS LICENSED CLINICAL SOCIAL WORK PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2026
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

335 N DUNTON AVE
EAST PATCHOGUE NY
11772-5543
US

IV. Provider business mailing address

335 N DUNTON AVE
EAST PATCHOGUE NY
11772-5543
US

V. Phone/Fax

Practice location:
  • Phone: 631-320-5363
  • Fax:
Mailing address:
  • Phone: 631-445-4786
  • Fax: 631-445-4786

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER FASSINO
Title or Position: LICENSED CLINICAL SOCIAL WORKER
Credential: LCSW
Phone: 631-445-4786