Provider Demographics
NPI:1013025626
Name:MOTT-INTERMAGGIO, PATRICIA JUNE (RLCSW, CASAC)
Entity Type:Individual
Prefix:MRS
First Name:PATRICIA
Middle Name:JUNE
Last Name:MOTT-INTERMAGGIO
Suffix:
Gender:F
Credentials:RLCSW, CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 NEWBERRY LN
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11968-2824
Mailing Address - Country:US
Mailing Address - Phone:631-287-0087
Mailing Address - Fax:631-287-0087
Practice Address - Street 1:10 NEWBERRY LN
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11968-2824
Practice Address - Country:US
Practice Address - Phone:631-287-0087
Practice Address - Fax:631-287-0087
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR047194-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01774285Medicaid
NYN68581Medicare ID - Type Unspecified