Provider Demographics
NPI:1265943989
Name:KOUTOUZIS, GEORGIA (LCSW)
Entity type:Individual
Prefix:
First Name:GEORGIA
Middle Name:
Last Name:KOUTOUZIS
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 1:425 OLD TOWN RD FL 1
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-3627
Mailing Address - Country:US
Mailing Address - Phone:631-209-7042
Mailing Address - Fax:631-840-4780
Practice Address - Street 1:425 OLD TOWN RD FL 1
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-3627
Practice Address - Country:US
Practice Address - Phone:631-209-7042
Practice Address - Fax:631-840-4780
Is Sole Proprietor?:No
Enumeration Date:2017-10-20
Last Update Date:2023-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101705104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker