Provider Demographics
NPI:1962828640
Name:FLANAGAN, TINA ROSE (LMHC)
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:ROSE
Last Name:FLANAGAN
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:ROSE
Other - Last Name:MENTZEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMHC
Mailing Address - Street 1:10 THRASHER AVE
Mailing Address - Street 2:
Mailing Address - City:BELLPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11713-1010
Mailing Address - Country:US
Mailing Address - Phone:631-627-4694
Mailing Address - Fax:
Practice Address - Street 1:1777 VETERANS MEMORIAL HWY STE 14
Practice Address - Street 2:
Practice Address - City:ISLANDIA
Practice Address - State:NY
Practice Address - Zip Code:11749-1555
Practice Address - Country:US
Practice Address - Phone:631-630-6439
Practice Address - Fax:631-630-6440
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-05
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005971101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY001254125Medicaid