Healthcare Provider Details

I. General information

NPI: 1114955416
Provider Name (Legal Business Name): TRACEY LYNNE CARDELLO LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 12/18/2020
Certification Date: 12/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47 OLD BROADWAY
GARDEN CITY PARK NY
11040-5012
US

IV. Provider business mailing address

47 OLD BROADWAY
GARDEN CITY PARK NY
11040
US

V. Phone/Fax

Practice location:
  • Phone: 516-996-2145
  • Fax:
Mailing address:
  • Phone: 516-935-6046
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number057203
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: