Basic Information
| Provider Information | |||||||||
| NPI: | 1255898342 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PSYCHOTHERAPY AT HOME, LCSW, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 FULTON ST APT M3 | ||||||||
| Address2: | |||||||||
| City: | FARMINGDALE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117353447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5163025645 | ||||||||
| FaxNumber: | 6316472058 | ||||||||
| Practice Location | |||||||||
| Address1: | 606 JOHNSON AVE STE 12 | ||||||||
| Address2: | |||||||||
| City: | BOHEMIA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117162687 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5163025645 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/25/2019 | ||||||||
| LastUpdateDate: | 02/25/2019 | ||||||||
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| AuthorizedOfficialLastName: | LEGRANDE | ||||||||
| AuthorizedOfficialFirstName: | DANA | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5163025645 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.