Provider Demographics
NPI:1205257417
Name:AFFECTIVE LCSW SERVICES PLLC
Entity type:Organization
Organization Name:AFFECTIVE LCSW SERVICES PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:DELSA
Authorized Official - Middle Name:JOHNSON
Authorized Official - Last Name:FAUCONIER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-R
Authorized Official - Phone:347-788-3775
Mailing Address - Street 1:97 BUSH AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10303-2215
Mailing Address - Country:US
Mailing Address - Phone:347-788-3775
Mailing Address - Fax:718-420-1032
Practice Address - Street 1:97 BUSH AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10303-2215
Practice Address - Country:US
Practice Address - Phone:347-788-3775
Practice Address - Fax:718-420-1032
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-16
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY083062104100000X
NY087435104100000X
1041C0700X
NY0754161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03546563Medicaid