Provider Demographics
NPI:1649660515
Name:GENTILE, MARISSA
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:GENTILE
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 1:1331 CONCORD PL
Mailing Address - Street 2:
Mailing Address - City:MERRICK
Mailing Address - State:NY
Mailing Address - Zip Code:11566-1538
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:333 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:NY
Practice Address - Zip Code:11520-1231
Practice Address - Country:US
Practice Address - Phone:516-623-3322
Practice Address - Fax:516-623-3526
Is Sole Proprietor?:No
Enumeration Date:2015-01-30
Last Update Date:2015-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY092991104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY092991OtherLICENSE