Provider Demographics
NPI:1821082959
Name:PENNETTI, SALVATORE (LCSW-R)
Entity Type:Individual
Prefix:MR
First Name:SALVATORE
Middle Name:
Last Name:PENNETTI
Suffix:
Gender:M
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-2250
Mailing Address - Country:US
Mailing Address - Phone:631-828-8600
Mailing Address - Fax:
Practice Address - Street 1:1000 MAIN ST
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2250
Practice Address - Country:US
Practice Address - Phone:631-828-8600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-05
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY070120-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN576B1Medicare ID - Type UnspecifiedPROVIDER ID
NYN576B1Medicare PIN