Healthcare Provider Details

I. General information

NPI: 1417978578
Provider Name (Legal Business Name): ELLEN LORI PECCHIA MS, LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 LAKE AVE
SAINT JAMES NY
11780-2938
US

IV. Provider business mailing address

204 LAKE AVE
SAINT JAMES NY
11780-2938
US

V. Phone/Fax

Practice location:
  • Phone: 516-330-4881
  • Fax:
Mailing address:
  • Phone: 516-330-4881
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number000469
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: