Provider Demographics
NPI:1710259841
Name:MITACCHIONE-ANDERSON, LAURAINE CAROLE
Entity Type:Individual
Prefix:MRS
First Name:LAURAINE
Middle Name:CAROLE
Last Name:MITACCHIONE-ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 LAUREL HOLLOW CT
Mailing Address - Street 2:
Mailing Address - City:WADING RIVER
Mailing Address - State:NY
Mailing Address - Zip Code:11792-1636
Mailing Address - Country:US
Mailing Address - Phone:631-929-6480
Mailing Address - Fax:
Practice Address - Street 1:201 SUNRISE HWY
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-1868
Practice Address - Country:US
Practice Address - Phone:631-289-2200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-06
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY76280911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical