Provider Demographics
NPI:1790848539
Name:GORENSTEIN, DIANE L (LCSW)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:L
Last Name:GORENSTEIN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:DIANE
Other - Middle Name:L
Other - Last Name:FONTANETTA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:7 FIREPLACE CT
Mailing Address - Street 2:
Mailing Address - City:EAST NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11731-6333
Mailing Address - Country:US
Mailing Address - Phone:631-462-3530
Mailing Address - Fax:631-462-3530
Practice Address - Street 1:7 FIREPLACE CT
Practice Address - Street 2:
Practice Address - City:EAST NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11731-6333
Practice Address - Country:US
Practice Address - Phone:631-462-3530
Practice Address - Fax:631-462-3530
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR028142-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN77821Medicare ID - Type UnspecifiedMEDICARE PROVIDER #