Healthcare Provider Details

I. General information

NPI: 1316638042
Provider Name (Legal Business Name): JACQUELINE M. HUTTER LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2023
Last Update Date: 05/15/2023
Certification Date: 05/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 BROADHOLLOW RD STE 402
MELVILLE NY
11747-4899
US

IV. Provider business mailing address

11 1ST AVE
EAST ISLIP NY
11730-2008
US

V. Phone/Fax

Practice location:
  • Phone: 631-385-7780
  • Fax:
Mailing address:
  • Phone: 631-339-1855
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number119441
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: