Provider Demographics
NPI:1700917366
Name:BLOCK, MICHAEL T (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:T
Last Name:BLOCK
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 FAIRHARBOR DR
Mailing Address - Street 2:
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-3342
Mailing Address - Country:US
Mailing Address - Phone:631-475-6492
Mailing Address - Fax:
Practice Address - Street 1:233 FAIRHARBOR DR
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-3342
Practice Address - Country:US
Practice Address - Phone:631-475-6492
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0326731041C0700X
225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY130781OtherVALUE OPTIONS PROVIDER #
NYR032673OtherSTATE LICENSE NUBER