MEDICARE: MR. THEODORE L HERNITCHE JR. LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	R038418-1	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	N7X831	OTHER	NY	EMPIRE BC/BS PROVIDER ID
2	A347769	OTHER	NY	VALUEOPTIONS VENDOR ID
3	P3385576	OTHER	NY	OXFORD PROVIDER #
4	7481499	OTHER	NY	GHI PIN #
5	R038418-1	OTHER	NY	NEW YORK STATE LICENSE #

General Provider Information

NPI Number	:	1083724124
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. THEODORE L HERNITCHE JR. LCSW

Provider Business Mailing Address
First Line	:	180 E MAIN ST
Second Line	:	STE 202
City	:	SMITHTOWN
State	:	NY
Zip	:	11787-2800
Country	:	US
Telephone Number	:	631-863-2499
Fax Number	:	631-406-6007

Provider Business Practice Location Address
First Line	:	368 VETERANS MEMORIAL HWY
Second Line	:
City	:	COMMACK
State	:	NY
Zip	:	11725-4322
Country	:	US
Telephone Number	:	631-863-2499
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	09/11/2017

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