Provider Demographics
NPI:1710095492
Name:SIMONETTI, CRISTA LIN (LCSW-R)
Entity Type:Individual
Prefix:
First Name:CRISTA
Middle Name:LIN
Last Name:SIMONETTI
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:MRS
Other - First Name:CRISTA
Other - Middle Name:LIN
Other - Last Name:SIMONETTI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW-R
Mailing Address - Street 1:269 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-8319
Mailing Address - Country:US
Mailing Address - Phone:631-885-5830
Mailing Address - Fax:
Practice Address - Street 1:269 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-8319
Practice Address - Country:US
Practice Address - Phone:631-885-5830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2012-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY073728101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health