Healthcare Provider Details

I. General information

NPI: 1902262959
Provider Name (Legal Business Name): LEANN RIDULFO LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2016
Last Update Date: 07/21/2021
Certification Date: 07/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1448 FIFTH AVENUE
BAYSHORE NY
11706
US

IV. Provider business mailing address

475 E MAIN ST STE 101
EAST PATCHOGUE NY
11772-3121
US

V. Phone/Fax

Practice location:
  • Phone: 631-309-6837
  • Fax:
Mailing address:
  • Phone: 631-363-2001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number096791-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: