Provider Demographics
NPI:1598377061
Name:INNES, ATHENA AMELIA
Entity Type:Individual
Prefix:
First Name:ATHENA
Middle Name:AMELIA
Last Name:INNES
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 1:158 RULAND RD
Mailing Address - Street 2:
Mailing Address - City:SELDEN
Mailing Address - State:NY
Mailing Address - Zip Code:11784-1840
Mailing Address - Country:US
Mailing Address - Phone:631-681-4953
Mailing Address - Fax:
Practice Address - Street 1:55 HORIZON DR
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-4436
Practice Address - Country:US
Practice Address - Phone:631-396-2300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-17
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP105689101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health