Healthcare Provider Details

I. General information

NPI: 1649816448
Provider Name (Legal Business Name): KERIANN OLEARY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2019
Last Update Date: 11/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 MARVIN ST
PATCHOGUE NY
11772-3958
US

IV. Provider business mailing address

132 MARVIN ST
PATCHOGUE NY
11772-3958
US

V. Phone/Fax

Practice location:
  • Phone: 631-365-2771
  • Fax:
Mailing address:
  • Phone: 631-365-2771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number08223-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number088223-1
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: