Provider Demographics
NPI:1124177472
Name:AUGENLICHT, ILENE ROBIN (LCSW)
Entity type:Individual
Prefix:PROF
First Name:ILENE
Middle Name:ROBIN
Last Name:AUGENLICHT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 FORREST AVE
Mailing Address - Street 2:
Mailing Address - City:CENTEREACH
Mailing Address - State:NY
Mailing Address - Zip Code:11720-3639
Mailing Address - Country:US
Mailing Address - Phone:631-467-3848
Mailing Address - Fax:631-451-4660
Practice Address - Street 1:2539 MIDDLE COUNTRY RD
Practice Address - Street 2:SUITE 4
Practice Address - City:CENTEREACH
Practice Address - State:NY
Practice Address - Zip Code:11720-3551
Practice Address - Country:US
Practice Address - Phone:631-467-3848
Practice Address - Fax:631-451-4660
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR040417-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02024739Medicaid
NY02024739Medicaid