Provider Demographics
NPI:1366890949
Name:SOUTH SHORE MENTAL HEALTH COUNSELING SERVICES,PC
Entity type:Organization
Organization Name:SOUTH SHORE MENTAL HEALTH COUNSELING SERVICES,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:J
Authorized Official - Last Name:ROCHE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-235-4481
Mailing Address - Street 1:200 CARLETON AVE STE D
Mailing Address - Street 2:
Mailing Address - City:EAST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11730-1222
Mailing Address - Country:US
Mailing Address - Phone:631-579-3503
Mailing Address - Fax:631-446-1136
Practice Address - Street 1:200 CARLETON AVE STE D
Practice Address - Street 2:
Practice Address - City:EAST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11730-1222
Practice Address - Country:US
Practice Address - Phone:631-579-3503
Practice Address - Fax:631-446-1136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-24
Last Update Date:2021-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
NY004685101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1578862728OtherNPI