Provider Demographics
NPI:1720183718
Name:HAKE, HEAWON (LCSW)
Entity Type:Individual
Prefix:
First Name:HEAWON
Middle Name:
Last Name:HAKE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 YALE ST
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-2855
Mailing Address - Country:US
Mailing Address - Phone:631-751-1300
Mailing Address - Fax:631-751-1300
Practice Address - Street 1:3771 NESCONSET HWY STE 208A
Practice Address - Street 2:
Practice Address - City:SOUTH SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11720-1154
Practice Address - Country:US
Practice Address - Phone:631-751-1300
Practice Address - Fax:631-751-1300
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY038650174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN5M461Medicare ID - Type Unspecified