Healthcare Provider Details

I. General information

NPI: 1245470103
Provider Name (Legal Business Name): NASSAU PSYCHOTHERAPY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2009
Last Update Date: 03/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 HEMPSTEAD AVE SUITE 143A
ROCKVILLE CENTRE NY
11570-4033
US

IV. Provider business mailing address

30 HEMPSTEAD AVE SUITE 143A
ROCKVILLE CENTRE NY
11570-4033
US

V. Phone/Fax

Practice location:
  • Phone: 516-594-0331
  • Fax: 516-538-8673
Mailing address:
  • Phone: 516-594-0331
  • Fax: 516-538-8673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPR 033101-1
License Number StateNY

VIII. Authorized Official

Name: MR. DAVID D. ILSON
Title or Position: PSYCHOTHERAPIST
Credential: LCSW
Phone: 516-594-0331