Provider Demographics
NPI:1851631782
Name:CHERTOK, RUSSELL JAMES (LCSW)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:JAMES
Last Name:CHERTOK
Suffix:
Gender:M
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:PO BOX 330
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-0330
Mailing Address - Country:US
Mailing Address - Phone:516-698-5511
Mailing Address - Fax:516-418-5377
Practice Address - Street 1:900 WALT WHITMAN RD STE LL1
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-2215
Practice Address - Country:US
Practice Address - Phone:516-698-5511
Practice Address - Fax:516-418-5377
Is Sole Proprietor?:No
Enumeration Date:2013-03-01
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY088454-1104100000X
NY085396-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03003069Medicaid