Healthcare Provider Details

I. General information

NPI: 1053502518
Provider Name (Legal Business Name): KERI MICA LCSW PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2007
Last Update Date: 08/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

176 N VILLAGE AVE SUITE 2E
ROCKVILLE CENTRE NY
11570-3800
US

IV. Provider business mailing address

111 HART STREET
LYNBROOK NY
11563-1760
US

V. Phone/Fax

Practice location:
  • Phone: 516-410-7138
  • Fax: 516-679-0736
Mailing address:
  • Phone: 516-410-7138
  • Fax: 516-679-0736

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MS. KERI LYNN MICA-SUTTMILLER
Title or Position: PRESIDENT
Credential: LCSW-R
Phone: 516-410-7138