Healthcare Provider Details

I. General information

NPI: 1922737683
Provider Name (Legal Business Name): OLD BROOKVILLE PSYCHOTHERAPY LCSW PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2022
Last Update Date: 06/08/2022
Certification Date: 06/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1129 NORTHERN BLVD SUITE 404- #0644
MANHASSET NY
11030
US

IV. Provider business mailing address

1129 NORTHERN BLVD SUITE 404- #0644
MANHASSET NY
11030
US

V. Phone/Fax

Practice location:
  • Phone: 516-749-1564
  • Fax:
Mailing address:
  • Phone: 516-749-1564
  • 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: GIGI CHARALAMBOUS
Title or Position: OWNER
Credential: LCSW-R
Phone: 516-749-1564