Provider Demographics
NPI:1649765207
Name:DIBELLA, KAITLIN (MHC)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:
Last Name:DIBELLA
Suffix:
Gender:F
Credentials:MHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 SOUTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:EAST PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-5811
Mailing Address - Country:US
Mailing Address - Phone:631-291-5741
Mailing Address - Fax:
Practice Address - Street 1:55 CARLETON AVE STE 5
Practice Address - Street 2:
Practice Address - City:EAST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11730-2133
Practice Address - Country:US
Practice Address - Phone:631-579-3503
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-26
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health