Provider Demographics
NPI:1689298044
Name:PERLONGO, MICHELLE RENEE (LMHC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RENEE
Last Name:PERLONGO
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:796 TYSENS LN
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-5620
Mailing Address - Country:US
Mailing Address - Phone:646-872-4354
Mailing Address - Fax:917-791-8248
Practice Address - Street 1:12 JEFFERSON BLVD STE 2
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-3330
Practice Address - Country:US
Practice Address - Phone:718-966-0317
Practice Address - Fax:917-791-8248
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-02
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010110101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health