Provider Demographics
NPI:1639640394
Name:LICANDRO, ELENA BETH (LMSW)
Entity Type:Individual
Prefix:
First Name:ELENA
Middle Name:BETH
Last Name:LICANDRO
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 1:1324 MOTOR PKWY STE 104
Mailing Address - Street 2:
Mailing Address - City:HAUPPAUGE
Mailing Address - State:NY
Mailing Address - Zip Code:11749-5226
Mailing Address - Country:US
Mailing Address - Phone:631-761-6700
Mailing Address - Fax:631-761-6699
Practice Address - Street 1:1324 MOTOR PKWY STE 104
Practice Address - Street 2:
Practice Address - City:HAUPPAUGE
Practice Address - State:NY
Practice Address - Zip Code:11749-5226
Practice Address - Country:US
Practice Address - Phone:631-761-6700
Practice Address - Fax:631-761-6699
Is Sole Proprietor?:No
Enumeration Date:2018-12-06
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY105308104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker