Healthcare Provider Details

I. General information

NPI: 1689331035
Provider Name (Legal Business Name): STACY PELLETTIERI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2021
Last Update Date: 11/19/2021
Certification Date: 11/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 JERICHO TPKE STE 104
JERICHO NY
11753-1320
US

IV. Provider business mailing address

149 COUNTRY CLUB DR
COMMACK NY
11725-4458
US

V. Phone/Fax

Practice location:
  • Phone: 516-680-5967
  • Fax:
Mailing address:
  • Phone: 516-680-5967
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: STACY LEIGH PELLETTIERI
Title or Position: OWNER/CLINICAL DIRECTOR
Credential: LCSW-R
Phone: 516-680-5967