MEDICARE: COMMUNITY GROWTH CENTER INC.

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1255903324
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMUNITY GROWTH CENTER INC.

Provider Business Mailing Address
First Line	:	4515 NESCONSET HWY
Second Line	:
City	:	PORT JEFFERSON STATION
State	:	NY
Zip	:	11776-2600
Country	:	US
Telephone Number	:	631-240-3471
Fax Number	:

Provider Business Practice Location Address
First Line	:	4515 NESCONSET HWY
Second Line	:
City	:	PORT JEFFERSON STATION
State	:	NY
Zip	:	11776-2600
Country	:	US
Telephone Number	:	631-240-3471
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. MICHAEL HOFFNER
Credential	:	LCSW
Telephone Number	:	516-306-6679

Provider Enumeration Date	:	07/16/2021
Last Update Date	:	07/16/2021

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