Provider Demographics
NPI:1013783638
Name:GLEASON, MICHAELA
Entity Type:Individual
Prefix:
First Name:MICHAELA
Middle Name:
Last Name:GLEASON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 JASMINE LN
Mailing Address - Street 2:
Mailing Address - City:KINGS PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11754-3924
Mailing Address - Country:US
Mailing Address - Phone:516-503-1642
Mailing Address - Fax:
Practice Address - Street 1:22 LAWRENCE AVE STE 211
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-3619
Practice Address - Country:US
Practice Address - Phone:631-360-2223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY100861104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker