Healthcare Provider Details

I. General information

NPI: 1457463598
Provider Name (Legal Business Name): MARY LEE HASBROUCK LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 ROUTE 25A STE A2
SHOREHAM NY
11786-1389
US

IV. Provider business mailing address

45 ROUTE 25A STE A2
SHOREHAM NY
11786-1389
US

V. Phone/Fax

Practice location:
  • Phone: 631-821-5056
  • Fax: 631-821-5056
Mailing address:
  • Phone: 631-821-5056
  • Fax: 631-821-5056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR022772-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: