Provider Demographics
NPI:1083755078
Name:SCALISE, DOMINICK (LCSW)
Entity Type:Individual
Prefix:MR
First Name:DOMINICK
Middle Name:
Last Name:SCALISE
Suffix:
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 1:70 MIDDLETON RD APT 16
Mailing Address - Street 2:
Mailing Address - City:BOHEMIA
Mailing Address - State:NY
Mailing Address - Zip Code:11716-3919
Mailing Address - Country:US
Mailing Address - Phone:631-835-6288
Mailing Address - Fax:
Practice Address - Street 1:35 CROOKED HILL RD
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-5415
Practice Address - Country:US
Practice Address - Phone:631-835-6288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR043521-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02425255Medicaid
NY02425255Medicaid