Provider Demographics
NPI:1972522902
Name:IMPACT LCSW COUNSELING SERVICES, PC
Entity Type:Organization
Organization Name:IMPACT LCSW COUNSELING SERVICES, PC
Other - Org Name:IMPACT COUNSELING SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:A
Authorized Official - Last Name:BRUNJES
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-R
Authorized Official - Phone:631-467-3181
Mailing Address - Street 1:2760 MIDDLE COUNTRY RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:LAKE GROVE
Mailing Address - State:NY
Mailing Address - Zip Code:11755-2113
Mailing Address - Country:US
Mailing Address - Phone:631-467-3181
Mailing Address - Fax:631-467-3185
Practice Address - Street 1:2760 MIDDLE COUNTRY RD
Practice Address - Street 2:SUITE 1
Practice Address - City:LAKE GROVE
Practice Address - State:NY
Practice Address - Zip Code:11755-2113
Practice Address - Country:US
Practice Address - Phone:631-467-3181
Practice Address - Fax:631-467-3185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR043837-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY11569751OtherCAQH
NY02756912Medicaid
NY11569751OtherCAQH