Healthcare Provider Details

I. General information

NPI: 1497925671
Provider Name (Legal Business Name): GINA MARIE TEDESCO LCSW-R
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2008
Last Update Date: 01/17/2023
Certification Date: 01/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

142 CARMAN ST
PATCHOGUE NY
11772-3908
US

IV. Provider business mailing address

142 CARMAN ST
PATCHOGUE NY
11772-3908
US

V. Phone/Fax

Practice location:
  • Phone: 929-373-6715
  • Fax:
Mailing address:
  • Phone: 929-373-6715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW6855
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number059766
License Number StateNY

VII. Legacy identifiers

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

# 1
Identifier7659369-00
Identifier TypeMEDICAID
Identifier StateFL
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: