Healthcare Provider Details

I. General information

NPI: 1619707650
Provider Name (Legal Business Name): COMMUNITY COUNSELING TOO LCSW SERVICES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2024
Last Update Date: 08/05/2024
Certification Date: 08/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

468 MAIN ST
MASTIC BEACH NY
11951-3407
US

IV. Provider business mailing address

468 MAIN ST
MASTIC BEACH NY
11951-3407
US

V. Phone/Fax

Practice location:
  • Phone: 631-294-0216
  • Fax: 631-772-6221
Mailing address:
  • Phone: 631-300-7910
  • Fax: 631-772-6221

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: HOLLY LEE GORDON
Title or Position: EXCUTIVE DIRECTOR
Credential: LCSWR
Phone: 631-294-0216