=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245645126
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LONG ISLAND MENTAL HEALTH WELLNESS COUNSELING PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2014
-----------------------------------------------------
Last Update Date | 06/30/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 293 CASTLE AVE STE 2F
-----------------------------------------------------
City | WESTBURY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11590-2025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-506-0836
-----------------------------------------------------
Fax | 516-506-0834
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 293 CASTLE AVE STE 2F
-----------------------------------------------------
City | WESTBURY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11590-2025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-506-0836
-----------------------------------------------------
Fax | 516-506-0834
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FOUNDER, DIRECTOR
-----------------------------------------------------
Name | MEGAN N WOODWARD
-----------------------------------------------------
Credential | M.A., LMHC, MBA, NCC
-----------------------------------------------------
Telephone | 516-506-0836
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 005680
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------