Healthcare Provider Details

I. General information

NPI: 1033065255
Provider Name (Legal Business Name): LIJO CHACKO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2026
Last Update Date: 03/09/2026
Certification Date: 03/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 HALLOCK AVE
PORT JEFFERSON STATION NY
11776-1256
US

IV. Provider business mailing address

2954 LAWRENCE DR
WANTAGH NY
11793-1049
US

V. Phone/Fax

Practice location:
  • Phone: 631-430-3318
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: