Provider Demographics
NPI:1750823506
Name:TAVOLACCI, JOHN (LCSW)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:TAVOLACCI
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 HOWARD ST
Mailing Address - Street 2:
Mailing Address - City:EAST WILLISTON
Mailing Address - State:NY
Mailing Address - Zip Code:11596-1421
Mailing Address - Country:US
Mailing Address - Phone:917-584-7068
Mailing Address - Fax:212-361-3761
Practice Address - Street 1:120 WALL ST
Practice Address - Street 2:17TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10005-3904
Practice Address - Country:US
Practice Address - Phone:212-361-1622
Practice Address - Fax:212-361-3761
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-10
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY069437-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical