Healthcare Provider Details

I. General information

NPI: 1477060374
Provider Name (Legal Business Name): JESSICA MIRABELLO LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2018
Last Update Date: 09/27/2024
Certification Date: 09/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 BI COUNTY BLVD STE 450
FARMINGDALE NY
11735-3995
US

IV. Provider business mailing address

776 RATHBUN AVE
STATEN ISLAND NY
10309-2409
US

V. Phone/Fax

Practice location:
  • Phone: 718-264-1640
  • Fax:
Mailing address:
  • Phone: 718-614-4943
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number004593
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number37PC01065500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: