Provider Demographics
NPI:1356720627
Name:GRACE COLASACCO, LICENSED MENTAL HEALTH COUNSELOR, PLLC
Entity type:Organization
Organization Name:GRACE COLASACCO, LICENSED MENTAL HEALTH COUNSELOR, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:
Authorized Official - Last Name:COLASACCO
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:631-741-6699
Mailing Address - Street 1:310 GRANADA PKWY
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-6303
Mailing Address - Country:US
Mailing Address - Phone:516-647-6064
Mailing Address - Fax:
Practice Address - Street 1:138 S 1ST ST
Practice Address - Street 2:SUITE 115
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757-4930
Practice Address - Country:US
Practice Address - Phone:631-741-6699
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-20
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006191101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty