Healthcare Provider Details

I. General information

NPI: 1033295498
Provider Name (Legal Business Name): TERRI ANNE COYLE FAMULARO LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2006
Last Update Date: 01/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1908 BROOKHAVEN AVE
FAR ROCKAWAY NY
11691-3626
US

IV. Provider business mailing address

1908 BROOKHAVEN AVE
FAR ROCKAWAY NY
11691-3626
US

V. Phone/Fax

Practice location:
  • Phone: 718-869-8400
  • Fax: 718-869-8405
Mailing address:
  • Phone: 718-869-8400
  • Fax: 718-869-8405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR054801-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: