Provider Demographics
NPI:1659452431
Name:SQUIRES, JEANNE R (LCSW,BCD)
Entity Type:Individual
Prefix:
First Name:JEANNE
Middle Name:R
Last Name:SQUIRES
Suffix:
Gender:F
Credentials:LCSW,BCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 CROYDON AVE
Mailing Address - Street 2:
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-1947
Mailing Address - Country:US
Mailing Address - Phone:631-696-7777
Mailing Address - Fax:631-696-1034
Practice Address - Street 1:21 CROYDON AVE
Practice Address - Street 2:
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-1947
Practice Address - Country:US
Practice Address - Phone:631-696-7777
Practice Address - Fax:631-696-1034
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0306771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY37412POtherHIP PROV NUMBER
NY37412POtherHIP PROV NUMBER
NYN76771Medicare ID - Type UnspecifiedMEDICARE PROVIDER