Provider Demographics
NPI:1659746485
Name:CANNISTRA, GINA MARIE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:GINA
Middle Name:MARIE
Last Name:CANNISTRA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 ELDRED AVE
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:NY
Mailing Address - Zip Code:13340-5119
Mailing Address - Country:US
Mailing Address - Phone:315-527-5332
Mailing Address - Fax:
Practice Address - Street 1:228 ELDRED AVE
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:NY
Practice Address - Zip Code:13340-5119
Practice Address - Country:US
Practice Address - Phone:315-527-5332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-04
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY07365711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical