=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275946493
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CJM COUNSELING LICENSED CLINICAL SOCIAL WORKERS P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2014
-----------------------------------------------------
Last Update Date | 09/18/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 145 HIGBIE LN
-----------------------------------------------------
City | WEST ISLIP
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11795-3236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-252-5740
-----------------------------------------------------
Fax | 631-743-6625
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 127 GATELOT AVE
-----------------------------------------------------
City | LAKE RONKONKOMA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11779-2266
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-252-5740
-----------------------------------------------------
Fax | 631-743-9983
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICER
-----------------------------------------------------
Name | MRS. JOAN MARIE RYAN
-----------------------------------------------------
Credential | LICENSED CLINICAL SO
-----------------------------------------------------
Telephone | 631-252-5740
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 077909
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 077909
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 102L00000X
-----------------------------------------------------
Taxonomy Name | Psychoanalyst
-----------------------------------------------------
License Number | 077909
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | 077909
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 077909
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 077909
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #8
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 077909
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------