Provider Demographics
NPI:1578716528
Name:MENNILLO, LINDA D (LMSW)
Entity Type:Individual
Prefix:MS
First Name:LINDA
Middle Name:D
Last Name:MENNILLO
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1536 TIBBITS AVE
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12180-3632
Mailing Address - Country:US
Mailing Address - Phone:518-339-7683
Mailing Address - Fax:
Practice Address - Street 1:1536 TIBBITS AVE
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-3632
Practice Address - Country:US
Practice Address - Phone:518-339-7683
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-03
Last Update Date:2008-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY062794-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist