Healthcare Provider Details

I. General information

NPI: 1154105609
Provider Name (Legal Business Name): PRACTICAL ONLINE THERAPY LCSW PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2023
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 ECKERT ST
HUNTINGTON STATION NY
11746-3842
US

IV. Provider business mailing address

45 ECKERT ST
HUNTINGTON STATION NY
11746-3842
US

V. Phone/Fax

Practice location:
  • Phone: 347-450-5542
  • Fax:
Mailing address:
  • Phone: 347-848-2237
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MRS. NIXALY YAKUBOV
Title or Position: FOUNDER
Credential: LCSW
Phone: 347-450-5542