Provider Demographics
NPI:1083724124
Name:HERNITCHE, THEODORE L JR (LCSW)
Entity Type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:L
Last Name:HERNITCHE
Suffix:JR
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 E MAIN ST
Mailing Address - Street 2:STE 202
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2800
Mailing Address - Country:US
Mailing Address - Phone:631-863-2499
Mailing Address - Fax:631-406-6007
Practice Address - Street 1:368 VETERANS MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-4322
Practice Address - Country:US
Practice Address - Phone:631-863-2499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2017-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR038418-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN7X831OtherEMPIRE BC/BS PROVIDER ID
NYA347769OtherVALUEOPTIONS VENDOR ID
NYP3385576OtherOXFORD PROVIDER #
NY7481499OtherGHI PIN #
NYR038418-1OtherNEW YORK STATE LICENSE #