Provider Demographics
NPI:1104160738
Name:MAVERICK FAMILY COUNSELING LCSW PLLC
Entity type:Organization
Organization Name:MAVERICK FAMILY COUNSELING LCSW PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CO-DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:THAYER
Authorized Official - Middle Name:
Authorized Official - Last Name:CASE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:845-679-8650
Mailing Address - Street 1:404 ZENA RD
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:NY
Mailing Address - Zip Code:12498-2626
Mailing Address - Country:US
Mailing Address - Phone:845-679-8650
Mailing Address - Fax:845-679-5485
Practice Address - Street 1:404 ZENA RD
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:NY
Practice Address - Zip Code:12498-2626
Practice Address - Country:US
Practice Address - Phone:845-679-8650
Practice Address - Fax:845-679-5485
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-20
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty