Provider Demographics
NPI:1366484339
Name:COLLETTI, MICHAEL ANTHONY (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:COLLETTI
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1809 AVENUE W
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-4701
Mailing Address - Country:US
Mailing Address - Phone:718-896-9090
Mailing Address - Fax:718-830-0724
Practice Address - Street 1:9745 QUEENS BLVD
Practice Address - Street 2:PENTHOUSE FLOOR
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-2101
Practice Address - Country:US
Practice Address - Phone:718-896-9090
Practice Address - Fax:718-830-0724
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY730736561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical