Basic Information
Provider Information | |||||||||
NPI: | 1730747320 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CONWAY | ||||||||
FirstName: | ALYZA | ||||||||
MiddleName: | D | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LMSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BAILEY | ||||||||
OtherFirstName: | ALYZA | ||||||||
OtherMiddleName: | D | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1 RESEARCH RD | ||||||||
Address2: |   | ||||||||
City: | RIDGE | ||||||||
State: | NY | ||||||||
PostalCode: | 119612701 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6317513000 | ||||||||
FaxNumber: | 6317510506 | ||||||||
Practice Location | |||||||||
Address1: | 1500 ROUTE 112 BLDG 4 | ||||||||
Address2: | SUITE101 | ||||||||
City: | PORT JEFFERSON STATION | ||||||||
State: | NY | ||||||||
PostalCode: | 11776 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6315748354 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/30/2019 | ||||||||
LastUpdateDate: | 11/04/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/04/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 096940 | NY | N |   | Behavioral Health & Social Service Providers | Social Worker |   | 1041C0700X | 096940 | NY | N |   | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 094350 | NY | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.