Provider Demographics
NPI:1275280620
Name:CRESCENT LIGHT COUNSELING, LCSW, PLLC
Entity Type:Organization
Organization Name:CRESCENT LIGHT COUNSELING, LCSW, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:TAYLOR
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHULTZ
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:631-617-3696
Mailing Address - Street 1:646 MAIN ST STE 102
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-2230
Mailing Address - Country:US
Mailing Address - Phone:631-772-9395
Mailing Address - Fax:
Practice Address - Street 1:646 MAIN ST STE 102
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2230
Practice Address - Country:US
Practice Address - Phone:631-772-9395
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-06
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty