Provider Demographics
NPI:1457423402
Name:FALK, AUDREY (LCSWR)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:FALK
Suffix:
Gender:F
Credentials:LCSWR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 ALICE LN
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-4275
Mailing Address - Country:US
Mailing Address - Phone:631-724-7750
Mailing Address - Fax:631-265-9226
Practice Address - Street 1:38 ALICE LN
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-4275
Practice Address - Country:US
Practice Address - Phone:631-724-7750
Practice Address - Fax:631-265-9226
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR027967-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN85431Medicare ID - Type Unspecified
NY220230Medicare UPIN