=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679074074
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LOUIS C WALTHALL, LCSWR, CASAC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2018
-----------------------------------------------------
Last Update Date | 02/22/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10 LODGE PL
-----------------------------------------------------
City | WEST BABYLON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11704-1608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-491-5720
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10 LODGE PL
-----------------------------------------------------
City | WEST BABYLON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11704-1608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-491-5817
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED CLINICAL SOCIAL WORKER
-----------------------------------------------------
Name | LOUIS C WALTHALL
-----------------------------------------------------
Credential | LCSWR, CASAC
-----------------------------------------------------
Telephone | 631-491-5720
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 9438
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 051661
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------