Healthcare Provider Details

I. General information

NPI: 1467635821
Provider Name (Legal Business Name): KATHERINE MARTHA SCOPE LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2007
Last Update Date: 12/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

939 JOHNSON AVE
RONKONKOMA NY
11779-6066
US

IV. Provider business mailing address

55 FERNDALE RD
ROCKY POINT NY
11778-9126
US

V. Phone/Fax

Practice location:
  • Phone: 631-471-7242
  • Fax:
Mailing address:
  • Phone: 631-741-7242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number002520
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: