Provider Demographics
NPI:1023255866
Name:BRICKLEY, ILENE A (LMSW)
Entity type:Individual
Prefix:MRS
First Name:ILENE
Middle Name:A
Last Name:BRICKLEY
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:MRS
Other - First Name:ILENE
Other - Middle Name:A
Other - Last Name:BRICKLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMSW
Mailing Address - Street 1:363 ROUTE 111
Mailing Address - Street 2:103
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-4756
Mailing Address - Country:US
Mailing Address - Phone:631-265-3133
Mailing Address - Fax:631-265-3205
Practice Address - Street 1:363 ROUTE 111
Practice Address - Street 2:SUITE 103
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-4756
Practice Address - Country:US
Practice Address - Phone:631-265-3133
Practice Address - Fax:631-265-3205
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-15
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY075188104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker