=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609923515
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NASSAU GUIDANCE COUNSELING & LICENSED CLINICAL SOCIAL WORK SERVICES PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/04/2007
-----------------------------------------------------
Last Update Date | 04/29/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1262 POWELL AVE
-----------------------------------------------------
City | MERRICK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11566-1811
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-829-4891
-----------------------------------------------------
Fax | 516-785-5698
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1262 POWELL AVE
-----------------------------------------------------
City | MERRICK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11566-1811
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-829-4891
-----------------------------------------------------
Fax | 516-785-5698
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MS. KATHLEEN DWYER
-----------------------------------------------------
Credential | LSCW
-----------------------------------------------------
Telephone | 516-826-4891
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | R026117
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------