Healthcare Provider Details

I. General information

NPI: 1285646067
Provider Name (Legal Business Name): CAROL S KRISHNAMOORTHY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

79 MIDDLEVILLE RD VAMC SOCIAL WORK & CHAPLAIN SERVICE (122)
NORTHPORT NY
11768-2200
US

IV. Provider business mailing address

46 WOODY LN
NORTHPORT NY
11768-3255
US

V. Phone/Fax

Practice location:
  • Phone: 631-261-4400
  • Fax: 631-266-6029
Mailing address:
  • Phone: 631-261-4400
  • Fax: 631-266-6029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR012861-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: