Provider Demographics
NPI:1720669708
Name:PALACIO, LYNETTE M (CASAC)
Entity Type:Individual
Prefix:
First Name:LYNETTE
Middle Name:M
Last Name:PALACIO
Suffix:
Gender:F
Credentials:CASAC
Other - Prefix:
Other - First Name:LYNETTE
Other - Middle Name:M
Other - Last Name:WYNTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:40 HARRISON ST APT 23H
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10013-0657
Mailing Address - Country:US
Mailing Address - Phone:347-225-3138
Mailing Address - Fax:718-613-7564
Practice Address - Street 1:880 BERGEN ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11238-3301
Practice Address - Country:US
Practice Address - Phone:718-613-7510
Practice Address - Fax:718-613-7564
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-20
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7651101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)