Provider Demographics
NPI:1790153021
Name:CEPEDA, LISETTE (LMSW)
Entity Type:Individual
Prefix:
First Name:LISETTE
Middle Name:
Last Name:CEPEDA
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 1:13 MARLBORO DR
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-3314
Mailing Address - Country:US
Mailing Address - Phone:631-346-1424
Mailing Address - Fax:
Practice Address - Street 1:50 W HAWTHORNE AVE # 3
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580-6220
Practice Address - Country:US
Practice Address - Phone:516-569-6600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY093350-11041S0200X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool