Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 104100000X | Social Worker | 052481-01 | NY |
NPI | 1003589573 |
---|---|
Provider Name | Jennifer Thieke |
First Address | Northport, NY 11768-3308 |
Second Address | Northport, NY 11768-3308 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 29/07/2021 |
Last Update Date | 29/07/2021 |