Provider Demographics
NPI:1457845059
Name:CIRCELLI LCSW SUPPORT SERVICES, PLLC
Entity Type:Organization
Organization Name:CIRCELLI LCSW SUPPORT SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MS
Authorized Official - First Name:JILL
Authorized Official - Middle Name:R
Authorized Official - Last Name:CIRCELLI
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-R
Authorized Official - Phone:315-725-0461
Mailing Address - Street 1:12 OVERBROOK CIR
Mailing Address - Street 2:
Mailing Address - City:NEW HARTFORD
Mailing Address - State:NY
Mailing Address - Zip Code:13413-2349
Mailing Address - Country:US
Mailing Address - Phone:315-725-0461
Mailing Address - Fax:
Practice Address - Street 1:12 OVERBROOK CIR
Practice Address - Street 2:
Practice Address - City:NEW HARTFORD
Practice Address - State:NY
Practice Address - Zip Code:13413-2349
Practice Address - Country:US
Practice Address - Phone:315-725-0461
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-18
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR080087-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYR080087-1OtherLICENSED CLINICAL SOCIAL WORKER