Healthcare Provider Details

I. General information

NPI: 1861892168
Provider Name (Legal Business Name): STEPHANIE PERSICO LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2014
Last Update Date: 12/01/2021
Certification Date: 12/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3251 ROUTE 112
MEDFORD NY
11763-1446
US

IV. Provider business mailing address

811 W JERICHO TPKE
SMITHTOWN NY
11787-3232
US

V. Phone/Fax

Practice location:
  • Phone: 631-451-6007
  • Fax:
Mailing address:
  • Phone: 631-882-1349
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: