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Provider Information for 1679074074


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LOUIS C WALTHALL, LCSWR, CASAC

Organization Subpart: NO

NPI: 1679074074
Last Updated: 2018-02-22
Certification Date:

Details

NameValue
NPI1679074074
Enumeration Date2018-02-22
NPI TypeNPI-2 Organization
StatusActive
Authorized Official Information Name: LOUIS C WALTHALL LCSWR, CASAC
Title: LICENSED CLINICAL SOCIAL WORKER
Phone: 6314915720
Mailing Address 10 LODGE PL
WEST BABYLON, NY 11704-1608
United States

Phone: 631-491-5817 | Fax:
 
Primary Practice Address 10 LODGE PL
WEST BABYLON, NY 11704-1608
United States

Phone: 631-491-5720 | Fax:
 
Secondary Practice Address(es)
Health Information Exchange
Endpoint TypeEndpointEndpoint DescriptionUseContent TypeAffiliationEndpoint Location
Other Identifiers
IssuerStateNumberOther Issuer
Taxonomy
Primary TaxonomySelected TaxonomyStateLicense Number
No 193200000X - Multi-Specialty Group
101YA0400X - Counselor - Addiction (Substance Use Disorder)
NY9438
Yes 193200000X - Multi-Specialty Group
1041C0700X - Social Worker - Clinical
NY051661