Healthcare Provider Details

I. General information

NPI: 1003609827
Provider Name (Legal Business Name): INTEGRATED PSYCHOTHERAPY COUNSELING LCSW, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2025
Last Update Date: 11/05/2025
Certification Date: 11/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MARINERS WAY
PORT JEFFERSON NY
11777-1848
US

IV. Provider business mailing address

100 MARINERS WAY
PORT JEFFERSON NY
11777-1848
US

V. Phone/Fax

Practice location:
  • Phone: 934-246-6042
  • Fax:
Mailing address:
  • Phone: 934-246-6042
  • Fax: 631-201-7390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JULIE STARK
Title or Position: CLINICIAN & PARTNER
Credential: LCSW
Phone: 934-246-6042