MEDICARE: MICHELLE RENEE PERLONGO LMHC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	010110	NY

General Provider Information

NPI Number	:	1689298044
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE RENEE PERLONGO LMHC

Provider Business Mailing Address
First Line	:	796 TYSENS LN
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10306-5620
Country	:	US
Telephone Number	:	646-872-4354
Fax Number	:	917-791-8248

Provider Business Practice Location Address
First Line	:	12 JEFFERSON BLVD STE 2
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10312-3330
Country	:	US
Telephone Number	:	718-966-0317
Fax Number	:	917-791-8248

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/02/2020
Last Update Date	:	06/02/2020

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