Provider Demographics
NPI:1093223455
Name:FASANO, GABRIELLE (LCSW)
Entity Type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:
Last Name:FASANO
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 1:20 WYCKOFF AVE
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-1420
Mailing Address - Country:US
Mailing Address - Phone:631-488-5118
Mailing Address - Fax:
Practice Address - Street 1:46 ROUTE 25A STE 3
Practice Address - Street 2:
Practice Address - City:SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-2806
Practice Address - Country:US
Practice Address - Phone:631-517-3345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-18
Last Update Date:2023-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY9909281104100000X
NY0919241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker