=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346995115
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SURREY PSYCHOTHERAPY LCSW PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/19/2022
-----------------------------------------------------
Last Update Date | 02/19/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 49 MAIN ST
-----------------------------------------------------
City | CHESTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10918-1330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-533-5063
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 245 CONKLINGTOWN RD
-----------------------------------------------------
City | GOSHEN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10924-5603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-301-0481
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. KATHERINE OLAYA COMPITUS
-----------------------------------------------------
Credential | DSW, LCSW
-----------------------------------------------------
Telephone | 917-301-0481
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------