Provider Demographics
NPI:1497096598
Name:PANDOLFI, MARK (LMSW)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:PANDOLFI
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 PARK AVENUE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11790
Mailing Address - Country:US
Mailing Address - Phone:631-427-3700
Mailing Address - Fax:
Practice Address - Street 1:220 MAIN ST
Practice Address - Street 2:
Practice Address - City:CENTER MORICHES
Practice Address - State:NY
Practice Address - Zip Code:11934-3516
Practice Address - Country:US
Practice Address - Phone:631-874-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-14
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY040008-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker