Provider Demographics
NPI:1659658581
Name:VENTIMIGLIA, LISA MICHELLE (LCSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MICHELLE
Last Name:VENTIMIGLIA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MICHELLE
Other - Last Name:TUMBARELLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:850 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-1604
Mailing Address - Country:US
Mailing Address - Phone:631-737-7406
Mailing Address - Fax:
Practice Address - Street 1:850 MAIN ST
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741-1604
Practice Address - Country:US
Practice Address - Phone:631-737-7406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-06
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0837741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical