Provider Demographics
NPI:1801215850
Name:ILLIANO, STACEY J (LMSW)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:J
Last Name:ILLIANO
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:J
Other - Last Name:KINNEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10819 ROCKAWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH OZONE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11420-1034
Mailing Address - Country:US
Mailing Address - Phone:718-845-2620
Mailing Address - Fax:718-845-9380
Practice Address - Street 1:10819 ROCKAWAY BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH OZONE PARK
Practice Address - State:NY
Practice Address - Zip Code:11420-1034
Practice Address - Country:US
Practice Address - Phone:718-845-2620
Practice Address - Fax:718-845-9380
Is Sole Proprietor?:No
Enumeration Date:2014-04-07
Last Update Date:2014-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY089565104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00089565Medicaid