=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972110724
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FIVE TOWNS WELLNESS LCSW PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2020
-----------------------------------------------------
Last Update Date | 09/20/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25 CENTRAL PARK W APT 1U
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10023-7214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-339-5567
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25 CENTRAL PARK W APT 1U
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10023-7214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-339-5567
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROVIDER/DIRECTOR
-----------------------------------------------------
Name | SARA GLASS
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 516-405-0362
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------