Provider Demographics
NPI:1669875936
Name:CATHERINE PROVENZANO
Entity type:Organization
Organization Name:CATHERINE PROVENZANO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MS
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:PROVENZANO
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:631-487-5162
Mailing Address - Street 1:1050 HALLOCK AVE
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-1214
Mailing Address - Country:US
Mailing Address - Phone:631-487-5162
Mailing Address - Fax:
Practice Address - Street 1:1050 HALLOCK AVE
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-1214
Practice Address - Country:US
Practice Address - Phone:631-487-5162
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-01
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0814381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty