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General NPI Number Information
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NPI Number | 1982970778
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Entity Type | Individual
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Provider Name | MARYLOU PACCIONE LCSW
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Gender | Female
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Dates
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Enumeration Date | 03/27/2012
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Last Update Date | 11/15/2023
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Provider Practice Location Address
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Address Line | 204 W BROADWAY
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City | PORT JEFFERSON
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State | NY
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Zip | 11777-1316
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Country | US
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Telephone | 631-793-5292
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Fax |
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Provider Business Mailing Address
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Address Line | 204 W BROADWAY
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City | PORT JEFFERSON
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State | NY
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Zip | 11777-1316
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Country | US
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Telephone | 631-793-5292
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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 | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 080703
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 050251
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License Number State | NY
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