Provider Demographics
NPI:1366684078
Name:SOUTHSHORE COUNSELING MEDIATION AND LICENSED CLINICAL SOCIAL WORK SERV
Entity Type:Organization
Organization Name:SOUTHSHORE COUNSELING MEDIATION AND LICENSED CLINICAL SOCIAL WORK SERV
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:CAVALERI
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:631-286-8282
Mailing Address - Street 1:36 EDGAR AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:NY
Mailing Address - Zip Code:11719-9655
Mailing Address - Country:US
Mailing Address - Phone:631-286-8282
Mailing Address - Fax:631-803-6793
Practice Address - Street 1:36 EDGAR AVE
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:NY
Practice Address - Zip Code:11719-9655
Practice Address - Country:US
Practice Address - Phone:631-286-8282
Practice Address - Fax:631-803-6793
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-26
Last Update Date:2016-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY075548-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty