Provider Demographics
NPI:1265946206
Name:PIEGARE, KATELYN
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:
Last Name:PIEGARE
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 1:1375 AKRON ST
Mailing Address - Street 2:
Mailing Address - City:COPIAGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11726-2931
Mailing Address - Country:US
Mailing Address - Phone:631-552-4240
Mailing Address - Fax:631-552-4241
Practice Address - Street 1:1375 AKRON ST
Practice Address - Street 2:
Practice Address - City:COPIAGUE
Practice Address - State:NY
Practice Address - Zip Code:11726-2931
Practice Address - Country:US
Practice Address - Phone:631-552-4240
Practice Address - Fax:631-552-4241
Is Sole Proprietor?:No
Enumeration Date:2017-11-29
Last Update Date:2017-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007980-1101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY744086628-00OtherFIDELIS