Provider Demographics
NPI:1376606368
Name:COLEY, MAUREEN (LCSW)
Entity Type:Individual
Prefix:
First Name:MAUREEN
Middle Name:
Last Name:COLEY
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 1:83 SEVILLE BLVD
Mailing Address - Street 2:
Mailing Address - City:SAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11782-2112
Mailing Address - Country:US
Mailing Address - Phone:631-563-5130
Mailing Address - Fax:631-567-4783
Practice Address - Street 1:335 MEETING HOUSE LN # B
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11968-5051
Practice Address - Country:US
Practice Address - Phone:631-287-5990
Practice Address - Fax:631-287-5995
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0463521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYR046352OtherHIP
NYR046352OtherHIP