Healthcare Provider Details

I. General information

NPI: 1790836070
Provider Name (Legal Business Name): GINA MARIE FATTIBENE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2007
Last Update Date: 08/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1380 ROANOKE AVE SUITE 201
RIVERHEAD NY
11901-2098
US

IV. Provider business mailing address

98 WOODLAWN AVE
SAINT JAMES NY
11780-2506
US

V. Phone/Fax

Practice location:
  • Phone: 631-369-4418
  • Fax: 631-369-4421
Mailing address:
  • Phone: 631-369-4418
  • Fax: 631-369-4421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0719131
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: