Provider Demographics
NPI:1790836070
Name:FATTIBENE, GINA MARIE (LCSW)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:MARIE
Last Name:FATTIBENE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:98 WOODLAWN AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JAMES
Mailing Address - State:NY
Mailing Address - Zip Code:11780-2506
Mailing Address - Country:US
Mailing Address - Phone:631-369-4418
Mailing Address - Fax:631-369-4421
Practice Address - Street 1:1380 ROANOKE AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2098
Practice Address - Country:US
Practice Address - Phone:631-369-4418
Practice Address - Fax:631-369-4421
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY07191311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical