Healthcare Provider Details

I. General information

NPI: 1356697700
Provider Name (Legal Business Name): GRACIANNA ETCHEVERRY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GRACE ETCHEVERRY LCSW

II. Dates (important events)

Enumeration Date: 08/02/2012
Last Update Date: 04/23/2024
Certification Date: 04/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 WALT WHITMAN RD
MELVILLE NY
11747-2293
US

IV. Provider business mailing address

WASCO STATE PRISON 701 SCOFIELD AVE
WASCO CA
93280
US

V. Phone/Fax

Practice location:
  • Phone: 516-698-5511
  • Fax:
Mailing address:
  • Phone: 661-758-8400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number089524
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW119446
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: