Provider Demographics
NPI:1922163245
Name:DATTILO TRABOULS, JO ANN (LCSW R BCD)
Entity Type:Individual
Prefix:MS
First Name:JO ANN
Middle Name:
Last Name:DATTILO TRABOULS
Suffix:
Gender:F
Credentials:LCSW R BCD
Other - Prefix:
Other - First Name:JO ANN
Other - Middle Name:
Other - Last Name:DATTILO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:137 BROOME AVE
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11509
Mailing Address - Country:US
Mailing Address - Phone:516-371-4118
Mailing Address - Fax:516-371-9423
Practice Address - Street 1:137 BROOME AVE
Practice Address - Street 2:
Practice Address - City:ATLANTIC BEACH
Practice Address - State:NY
Practice Address - Zip Code:11509
Practice Address - Country:US
Practice Address - Phone:516-371-4118
Practice Address - Fax:516-371-9423
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR043372-1103TP0814X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TP0814XBehavioral Health & Social Service ProvidersPsychologistPsychoanalysis
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker