Healthcare Provider Details

I. General information

NPI: 1376466748
Provider Name (Legal Business Name): STACY ANN BARTHOLOMEW LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1227 MAIN ST
PORT JEFFERSON NY
11777-2227
US

IV. Provider business mailing address

5 BLACKBERRY LN
CENTER MORICHES NY
11934-1412
US

V. Phone/Fax

Practice location:
  • Phone: 631-985-0903
  • Fax:
Mailing address:
  • Phone: 631-697-8204
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number103122
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: