Healthcare Provider Details

I. General information

NPI: 1972522902
Provider Name (Legal Business Name): IMPACT LCSW COUNSELING SERVICES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2760 MIDDLE COUNTRY RD SUITE 1
LAKE GROVE NY
11755-2113
US

IV. Provider business mailing address

2760 MIDDLE COUNTRY RD SUITE 1
LAKE GROVE NY
11755-2113
US

V. Phone/Fax

Practice location:
  • Phone: 631-467-3181
  • Fax: 631-467-3185
Mailing address:
  • Phone: 631-467-3181
  • Fax: 631-467-3185

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR043837-1
License Number StateNY

VIII. Authorized Official

Name: CAROL A BRUNJES
Title or Position: CEO/CLINICAL DIRECTOR
Credential: LCSW-R
Phone: 631-467-3181