Provider Demographics
NPI:1215000799
Name:DESIMONE, MARY R (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:R
Last Name:DESIMONE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MISS
Other - First Name:MARY
Other - Middle Name:R
Other - Last Name:GRILLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:90 FREEMAN AVE
Mailing Address - Street 2:
Mailing Address - City:ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11751-1418
Mailing Address - Country:US
Mailing Address - Phone:631-968-8838
Mailing Address - Fax:631-647-5423
Practice Address - Street 1:430 W MAIN ST
Practice Address - Street 2:SUITE B
Practice Address - City:BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11702-3003
Practice Address - Country:US
Practice Address - Phone:631-647-5423
Practice Address - Fax:631-647-5423
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0562671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN615G1Medicare UPIN