Provider Demographics
NPI:1245794627
Name:COOGAN, ANNALESE (LMSW)
Entity Type:Individual
Prefix:
First Name:ANNALESE
Middle Name:
Last Name:COOGAN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 WILDFLOWER CT APT 11
Mailing Address - Street 2:
Mailing Address - City:MORICHES
Mailing Address - State:NY
Mailing Address - Zip Code:11955-2030
Mailing Address - Country:US
Mailing Address - Phone:631-291-0157
Mailing Address - Fax:
Practice Address - Street 1:75 WILDFLOWER CT APT 11
Practice Address - Street 2:
Practice Address - City:MORICHES
Practice Address - State:NY
Practice Address - Zip Code:11955-2030
Practice Address - Country:US
Practice Address - Phone:631-291-0157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-30
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY102271-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY102271-1Medicaid