Provider Demographics
NPI:1215365739
Name:LY, PHUNG MY (LPCC, CDAC-II, MSCP)
Entity Type:Individual
Prefix:
First Name:PHUNG MY
Middle Name:
Last Name:LY
Suffix:
Gender:F
Credentials:LPCC, CDAC-II, MSCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 PARK AVE S
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-1502
Mailing Address - Country:US
Mailing Address - Phone:267-999-9534
Mailing Address - Fax:
Practice Address - Street 1:1 GATEWAY CTR STE 2600
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07102-5323
Practice Address - Country:US
Practice Address - Phone:888-528-7618
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-18
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARA9280413101YA0400X
CALPCC6684101YP2500X
NJ37PC00989900101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)