Healthcare Provider Details

I. General information

NPI: 1356832802
Provider Name (Legal Business Name): AARON VITO BAIL LMSW, CPRP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2018
Last Update Date: 05/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

939 JOHNSON AVE
RONKONKOMA NY
11779
US

IV. Provider business mailing address

1380 ROANOKE AVE STE 100
RIVERHEAD NY
11901-2035
US

V. Phone/Fax

Practice location:
  • Phone: 631-471-7242
  • Fax:
Mailing address:
  • Phone: 631-672-3566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number103641-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: