Healthcare Provider Details

I. General information

NPI: 1659284305
Provider Name (Legal Business Name): INTEGRATIVE LICENSED CLINICAL SOCIAL WORK PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2026
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 CLIFF RD W
WADING RIVER NY
11792-1240
US

IV. Provider business mailing address

112 CLIFF RD W
WADING RIVER NY
11792-1240
US

V. Phone/Fax

Practice location:
  • Phone: 631-838-7183
  • Fax:
Mailing address:
  • Phone: 631-838-7183
  • Fax:

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: JOSHUA HENDRICKSON
Title or Position: OWNER
Credential: PHD LCSW
Phone: 631-838-7183