Provider Demographics
NPI:1598825200
Name:DESIMONE, VINCENT LOUIS (LCSW)
Entity Type:Individual
Prefix:MR
First Name:VINCENT
Middle Name:LOUIS
Last Name:DESIMONE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 WATERVIEW DR
Mailing Address - Street 2:
Mailing Address - City:CENTERPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11721-1636
Mailing Address - Country:US
Mailing Address - Phone:631-680-7866
Mailing Address - Fax:631-261-7095
Practice Address - Street 1:363 ROUTE 111
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-4756
Practice Address - Country:US
Practice Address - Phone:631-680-7866
Practice Address - Fax:631-261-7095
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0693151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02470097Medicaid
NYNG 2381Medicare ID - Type Unspecified