Provider Demographics
NPI:1568959823
Name:TRECCAGNOLI, KAITLYN
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:
Last Name:TRECCAGNOLI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2257 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-6255
Mailing Address - Country:US
Mailing Address - Phone:631-848-9613
Mailing Address - Fax:
Practice Address - Street 1:710 MAIN ST
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2278
Practice Address - Country:US
Practice Address - Phone:631-716-5881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-21
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY104100000X
NY1016981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker