Provider Demographics
NPI:1417243353
Name:DONALDSON, LARRY THOMAS (CASAC)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:THOMAS
Last Name:DONALDSON
Suffix:
Gender:M
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 RIDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11738-1618
Mailing Address - Country:US
Mailing Address - Phone:631-772-8547
Mailing Address - Fax:
Practice Address - Street 1:129 RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:FARMINGVILLE
Practice Address - State:NY
Practice Address - Zip Code:11738-1618
Practice Address - Country:US
Practice Address - Phone:631-772-8547
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-20
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY18414101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)