Provider Demographics
NPI:1083255251
Name:ABALCO, ANGELYSE (LMSW)
Entity Type:Individual
Prefix:
First Name:ANGELYSE
Middle Name:
Last Name:ABALCO
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:ANGELYSE
Other - Middle Name:
Other - Last Name:KENNGOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:606 JOHNSON AVE STE 34
Mailing Address - Street 2:
Mailing Address - City:BOHEMIA
Mailing Address - State:NY
Mailing Address - Zip Code:11716-2689
Mailing Address - Country:US
Mailing Address - Phone:631-525-7572
Mailing Address - Fax:
Practice Address - Street 1:161 E MAIN ST
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2879
Practice Address - Country:US
Practice Address - Phone:631-360-7578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-30
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY098471104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker