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General NPI Number Information
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NPI Number | 1134609548
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Entity Type | Individual
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Provider Name | MARISSA ROSE TAVELLA LMSW
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Gender | Female
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Dates
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Enumeration Date | 08/15/2018
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Last Update Date | 08/15/2018
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Provider Practice Location Address
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Address Line | 116 W 32ND ST FL 8
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City | NEW YORK
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State | NY
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Zip | 10001-3212
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Country | US
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Telephone | 212-564-2350
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Fax | 646-390-2767
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Provider Business Mailing Address
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Address Line | 64 MCARTHUR LN
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City | SMITHTOWN
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State | NY
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Zip | 11787-3935
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Country | US
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Telephone | 631-459-7578
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | 103372-1
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License Number State | NY
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