Healthcare Provider Details

I. General information

NPI: 1184719833
Provider Name (Legal Business Name): JOY MICHELE GOOTKIN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 REDWOOD LN
SOUTH SETAUKET NY
11720-1431
US

IV. Provider business mailing address

14 REDWOOD LN
SOUTH SETAUKET NY
11720-1431
US

V. Phone/Fax

Practice location:
  • Phone: 631-696-8006
  • Fax: 631-696-8006
Mailing address:
  • Phone: 631-696-8006
  • Fax: 631-696-8006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number073244-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: