Healthcare Provider Details

I. General information

NPI: 1821047002
Provider Name (Legal Business Name): ERNEST LEUCI LCSWR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 08/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 PREMIER CT
PRT JEFF STA NY
11776-3198
US

IV. Provider business mailing address

3 PREMIER CT
PRT JEFF STA NY
11776-3198
US

V. Phone/Fax

Practice location:
  • Phone: 631-476-7119
  • Fax:
Mailing address:
  • Phone: 631-476-7119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberPR053666-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: