Provider Demographics
NPI:1700663234
Name:GORWITZ, PHYLLIS H
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:H
Last Name:GORWITZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MUSKET PL
Mailing Address - Street 2:
Mailing Address - City:EAST SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-1827
Mailing Address - Country:US
Mailing Address - Phone:516-449-4686
Mailing Address - Fax:
Practice Address - Street 1:8 W MAIN ST STE 7
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-3039
Practice Address - Country:US
Practice Address - Phone:631-828-8874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-08
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst