Provider Demographics
NPI:1104032929
Name:CONWAY, THOMAS EUGENE (LCSW)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:EUGENE
Last Name:CONWAY
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 1:92 BROOKSITE DRIVE
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787
Mailing Address - Country:US
Mailing Address - Phone:631-864-2778
Mailing Address - Fax:631-864-9201
Practice Address - Street 1:994 W JERICHO TURNPIKE
Practice Address - Street 2:SUITE 202
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787
Practice Address - Country:US
Practice Address - Phone:631-864-2778
Practice Address - Fax:631-864-9201
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR02600011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN3044Medicare ID - Type Unspecified