Provider Demographics
NPI:1720007354
Name:MACOLINO, MICHELLE MARIA (LMSW)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MARIA
Last Name:MACOLINO
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 DEAL RD
Mailing Address - Street 2:
Mailing Address - City:ISLAND PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11558-1449
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6729 MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:NY
Practice Address - Zip Code:11385-7063
Practice Address - Country:US
Practice Address - Phone:718-456-7001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY067305-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00244624Medicaid