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General NPI Number Information
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NPI Number | 1669860573
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Entity Type | Organization
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Legal Business Name | SHOREHAM PSYCHOTHERAPY SERVICES LCSW PLLC
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Dates
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Enumeration Date | 12/30/2014
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Last Update Date | 12/30/2014
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Provider Practice Location Address
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Address Line | 45 ROUTE 25A SUITE A2
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City | SHOREHAM
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State | NY
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Zip | 11786-1389
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Country | US
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Telephone | 631-821-5056
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Fax | 631-821-5056
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Provider Business Mailing Address
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Address Line | 45 ROUTE 25A SUITE A2
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City | SHOREHAM
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State | NY
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Zip | 11786-1389
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Country | US
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Telephone | 631-821-5056
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Fax | 631-821-5056
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Authorized Official
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Title or Position | PRESIDENT
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Name | MARY LEE HASBROUCK
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Credential | LCSW
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Telephone | 631-821-5056
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 117957
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License Number State | MA
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | R022772
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License Number State | NY
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