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General NPI Number Information
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NPI Number | 1174005862
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Entity Type | Organization
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Legal Business Name | WHOLEHEARTED LIVING LCSW PC
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Dates
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Enumeration Date | 08/30/2018
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Last Update Date | 08/30/2018
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Provider Practice Location Address
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Address Line | 23 CANDEE AVENUE
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City | SAYVILLE
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State | NY
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Zip | 11782
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Country | US
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Telephone | 914-400-5199
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Fax |
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Provider Business Mailing Address
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Address Line | 7 FLINTLOCK DRIVE
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City | SHIRLEY
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State | NY
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Zip | 11967
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Country | US
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Telephone | 914-400-5199
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Fax |
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Authorized Official
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Title or Position | OWNER/LICENSED CLINICAL SOCIAL WORK
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Name | MS. MELISSA MACKO
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Credential | LCSW
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Telephone | 914-400-5199
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 079585-2
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License Number State | NY
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