Provider Demographics
NPI:1407273352
Name:IZZO, KRYSTIE MARIE (LMHC)
Entity Type:Individual
Prefix:MRS
First Name:KRYSTIE
Middle Name:MARIE
Last Name:IZZO
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:MS
Other - First Name:KRYSTIE
Other - Middle Name:MARIE
Other - Last Name:DECICCO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMHC
Mailing Address - Street 1:2460 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-6612
Mailing Address - Country:US
Mailing Address - Phone:646-220-4406
Mailing Address - Fax:
Practice Address - Street 1:2460 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314
Practice Address - Country:US
Practice Address - Phone:718-477-0228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-27
Last Update Date:2018-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007045-1101YM0800X
NY007045101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health