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General NPI Number Information
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NPI Number | 1992112510
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Entity Type | Organization
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Legal Business Name | SOUTH BAY COUNSELING, LCSW PC
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Dates
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Enumeration Date | 07/15/2014
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Last Update Date | 05/05/2017
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Provider Practice Location Address
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Address Line | 191 BROADWAY
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City | AMITYVILLE
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State | NY
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Zip | 11701-2790
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Country | US
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Telephone | 631-264-0058
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Fax | 631-264-0056
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Provider Business Mailing Address
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Address Line | 191 BROADWAY
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City | AMITYVILLE
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State | NY
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Zip | 11701-2790
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Country | US
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Telephone | 631-264-0058
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Fax | 631-264-0056
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Authorized Official
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Title or Position | PRESIDENT/OWNER
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Name | ELISSA GRUNBLATT
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Credential | LCSW-R
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Telephone | 631-264-0058
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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 | 069889
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License Number State | NY
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