Healthcare Provider Details

I. General information

NPI: 1518201011
Provider Name (Legal Business Name): GINA ANN CONDURSO LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2012
Last Update Date: 11/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 SYCAMORE AVE SUITE 39
BOHEMIA NY
11716-1738
US

IV. Provider business mailing address

1650 SYCAMORE AVE SUITE 39
BOHEMIA NY
11716-1738
US

V. Phone/Fax

Practice location:
  • Phone: 631-758-8290
  • Fax:
Mailing address:
  • Phone: 631-758-8290
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number078843-1
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: