Healthcare Provider Details

I. General information

NPI: 1376732289
Provider Name (Legal Business Name): MARCI ANN MIRISOLA MA, LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2007
Last Update Date: 04/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 OAK ST SUITE 7
PATCHOGUE NY
11772-2841
US

IV. Provider business mailing address

31 OAK ST SUITE 7
PATCHOGUE NY
11772-2841
US

V. Phone/Fax

Practice location:
  • Phone: 631-317-1775
  • Fax:
Mailing address:
  • Phone: 631-317-1775
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number006208
License Number StateNY

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: