Healthcare Provider Details

I. General information

NPI: 1043593932
Provider Name (Legal Business Name): PAMELA ANN BABCOCK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2011
Last Update Date: 03/19/2021
Certification Date: 03/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7555 MAIN RD
MATTITUCK NY
11952-1516
US

IV. Provider business mailing address

1380 JASMINE LN
SOUTHOLD NY
11971-3072
US

V. Phone/Fax

Practice location:
  • Phone: 631-298-8642
  • Fax:
Mailing address:
  • Phone: 631-765-1709
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number084454-1
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: