Provider Demographics
NPI:1245663293
Name:IACOVELLI, MICHAEL ANTHONY (LMSW)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:IACOVELLI
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 STRATFORD GRN
Mailing Address - Street 2:
Mailing Address - City:FARMINGDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11735-2549
Mailing Address - Country:US
Mailing Address - Phone:631-965-0114
Mailing Address - Fax:
Practice Address - Street 1:11 ROUTE 111
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-3739
Practice Address - Country:US
Practice Address - Phone:631-920-8300
Practice Address - Fax:631-920-8460
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-13
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY089076104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker