Provider Demographics
NPI:1013036748
Name:MISTRETTA, MARIE (LCSW)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:
Last Name:MISTRETTA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 HILLSIDE AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WILLISTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11596-2347
Mailing Address - Country:US
Mailing Address - Phone:516-248-4581
Mailing Address - Fax:516-248-4581
Practice Address - Street 1:101 HILLSIDE AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:WILLISTON PARK
Practice Address - State:NY
Practice Address - Zip Code:11596-2347
Practice Address - Country:US
Practice Address - Phone:516-248-4581
Practice Address - Fax:516-248-4581
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0169681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP3637040OtherOXFORD
NY062688OtherVALUE OPTIONS
NYNX4412OtherBC BS EMPIRE NY
NY7404230OtherGHI NY
NYNX4412OtherBC BS EMPIRE NY