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General NPI Number Information
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NPI Number | 1760694947
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Entity Type | Organization
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Legal Business Name | IMPACT COUNSELING SERVICES I, INC.
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Dates
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Enumeration Date | 05/03/2007
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Last Update Date | 04/22/2015
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Provider Practice Location Address
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Address Line | 2760 MIDDLE COUNTRY RD SUITE 1
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City | LAKE GROVE
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State | NY
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Zip | 11755-2113
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Country | US
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Telephone | 631-467-3182
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Fax | 631-467-3178
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Provider Business Mailing Address
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Address Line | 2760 MIDDLE COUNTRY RD SUITE 1
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City | LAKE GROVE
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State | NY
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Zip | 11755-2113
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Country | US
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Telephone | 631-467-3182
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Fax | 631-467-3178
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Authorized Official
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Title or Position | CEO CLINICAL DIRECTOR
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Name | MRS. CAROL ANN BRUNJES
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Credential | LCSW R
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Telephone | 631-467-3182
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 080411616
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License Number State | NY
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