Healthcare Provider Details

I. General information

NPI: 1063437911
Provider Name (Legal Business Name): RESIDENTIAL PSYCHOTHERAPIES,CSW,PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 04/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42 OLD NORTHPORT RD.
KINGS PARK NY
11754
US

IV. Provider business mailing address

42 OLD NORTHPORT RD.
KINGS PARK NY
11754
US

V. Phone/Fax

Practice location:
  • Phone: 631-366-0417
  • Fax:
Mailing address:
  • Phone: 631-366-0417
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberRO26799
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR26799
License Number StateNY

VIII. Authorized Official

Name: MR. RICHARD NEMIROFF
Title or Position: CEO
Credential: LCSW
Phone: 631-366-0417