Provider Demographics
NPI:1295144616
Name:LICENSED MASTER SOCIAL WORK SERVICES, PLLC
Entity type:Organization
Organization Name:LICENSED MASTER SOCIAL WORK SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:CHERTOK
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW, CASAC-T
Authorized Official - Phone:631-524-4870
Mailing Address - Street 1:416 SCRANTON AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:LYNBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11563-3336
Mailing Address - Country:US
Mailing Address - Phone:516-698-5511
Mailing Address - Fax:
Practice Address - Street 1:416 SCRANTON AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:LYNBROOK
Practice Address - State:NY
Practice Address - Zip Code:11563-3336
Practice Address - Country:US
Practice Address - Phone:516-698-5511
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-11
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY088454104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty