Provider Demographics
NPI:1669860573
Name:SHOREHAM PSYCHOTHERAPY SERVICES LCSW PLLC
Entity Type:Organization
Organization Name:SHOREHAM PSYCHOTHERAPY SERVICES LCSW PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARY LEE
Authorized Official - Middle Name:
Authorized Official - Last Name:HASBROUCK
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:631-821-5056
Mailing Address - Street 1:45 ROUTE 25A
Mailing Address - Street 2:SUITE A2
Mailing Address - City:SHOREHAM
Mailing Address - State:NY
Mailing Address - Zip Code:11786-1389
Mailing Address - Country:US
Mailing Address - Phone:631-821-5056
Mailing Address - Fax:631-821-5056
Practice Address - Street 1:45 ROUTE 25A
Practice Address - Street 2:SUITE A2
Practice Address - City:SHOREHAM
Practice Address - State:NY
Practice Address - Zip Code:11786-1389
Practice Address - Country:US
Practice Address - Phone:631-821-5056
Practice Address - Fax:631-821-5056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-30
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0227721041C0700X
MA1179571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01475396Medicaid
NY10498656OtherCAQH
NY10498656OtherCAQH