Healthcare Provider Details

I. General information

NPI: 1659916278
Provider Name (Legal Business Name): JOSHUA D HENDRICKSON LCSW PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2019
Last Update Date: 11/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1394 ROANOKE AVE STE A
RIVERHEAD NY
11901-2100
US

IV. Provider business mailing address

1394 ROANOKE AVE STE A
RIVERHEAD NY
11901-2100
US

V. Phone/Fax

Practice location:
  • Phone: 631-838-7183
  • Fax:
Mailing address:
  • Phone: 631-838-7183
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JOSHUA HENDRICKSON
Title or Position: PROVIDER
Credential:
Phone: 631-838-7183