Healthcare Provider Details

I. General information

NPI: 1649481912
Provider Name (Legal Business Name): WILLIAM O'LEARY LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3771 NESCONSET HWY SUITE 208B
SOUTH SETAUKET NY
11720-1163
US

IV. Provider business mailing address

22 PARSONS DR
STONY BROOK NY
11790-2615
US

V. Phone/Fax

Practice location:
  • Phone: 631-921-9138
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number072250
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: