Provider Demographics
NPI:1659365914
Name:MAIORELLA, RICHARD (LCSW)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:
Last Name:MAIORELLA
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 1:798 SYLVAN AVE
Mailing Address - Street 2:
Mailing Address - City:BAYPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11705-1552
Mailing Address - Country:US
Mailing Address - Phone:631-472-2125
Mailing Address - Fax:
Practice Address - Street 1:107 W MAIN ST
Practice Address - Street 2:SUNRISE COUNSELING CENTER
Practice Address - City:EAST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11730
Practice Address - Country:US
Practice Address - Phone:631-666-1615
Practice Address - Fax:631-666-1709
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-01
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR038750-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN58331Medicare ID - Type Unspecified