Provider Demographics
NPI:1093323800
Name:TESSEYMAN, CAITLIN ELIZABETH
Entity Type:Individual
Prefix:
First Name:CAITLIN
Middle Name:ELIZABETH
Last Name:TESSEYMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 WILLOWOOD LN
Mailing Address - Street 2:
Mailing Address - City:CORAM
Mailing Address - State:NY
Mailing Address - Zip Code:11727-1130
Mailing Address - Country:US
Mailing Address - Phone:631-796-3471
Mailing Address - Fax:
Practice Address - Street 1:1413 STONY BROOK RD
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-2214
Practice Address - Country:US
Practice Address - Phone:631-444-0101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-17
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY109231-01104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker