Provider Demographics
NPI:1265717078
Name:PERVELIS, CRISTA LYN (LCSW)
Entity type:Individual
Prefix:MRS
First Name:CRISTA
Middle Name:LYN
Last Name:PERVELIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:CRISTA
Other - Middle Name:LYN
Other - Last Name:HASLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:101 FIREPLACE NECK ROAD
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:NY
Mailing Address - Zip Code:11719
Mailing Address - Country:US
Mailing Address - Phone:631-730-1700
Mailing Address - Fax:
Practice Address - Street 1:101 FIREPLACE NECK ROAD
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:NY
Practice Address - Zip Code:11719
Practice Address - Country:US
Practice Address - Phone:631-730-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-13
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY078407-11041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool