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General NPI Number Information
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NPI Number | 1518465806
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Entity Type | Individual
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Provider Name | ERICA LYNN QUALLY LMSW
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Gender | Female
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Dates
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Enumeration Date | 02/01/2018
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Last Update Date | 02/01/2018
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Provider Practice Location Address
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Address Line | 939 JOHNSON AVE
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City | RONKONKOMA
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State | NY
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Zip | 11779-6066
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Country | US
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Telephone | 631-369-4418
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Fax |
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Provider Business Mailing Address
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Address Line | 29 VERNON AVE
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City | MASTIC
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State | NY
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Zip | 11950-2305
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Country | US
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Telephone | 631-514-4147
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | 102017
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License Number State | NY
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