Provider Demographics
NPI:1710478326
Name:TROMELLO, JENNIFER LUCIA (LCSW CASAC OWDS)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LUCIA
Last Name:TROMELLO
Suffix:
Gender:F
Credentials:LCSW CASAC OWDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 782
Mailing Address - Street 2:
Mailing Address - City:CORAM
Mailing Address - State:NY
Mailing Address - Zip Code:11727-0782
Mailing Address - Country:US
Mailing Address - Phone:631-392-8534
Mailing Address - Fax:
Practice Address - Street 1:63 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:CORAM
Practice Address - State:NY
Practice Address - Zip Code:11727-4201
Practice Address - Country:US
Practice Address - Phone:631-392-8534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-21
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY24384101YA0400X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY06073358Medicaid