=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417830027
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RESILIENT ROOTS-LICENSED CLINICAL SOCIAL WORK SERVICES, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2025
-----------------------------------------------------
Last Update Date | 07/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 27 DEEP LN
-----------------------------------------------------
City | WANTAGH
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11793-1805
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-404-9884
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 7143
-----------------------------------------------------
City | WANTAGH
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11793-0743
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-404-9884
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TRICIA MCCLOSKEY
-----------------------------------------------------
Credential | LCSW, M-CASAC, MCPC
-----------------------------------------------------
Telephone | 516-404-9884
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------