Provider Demographics
NPI:1770175853
Name:DIBENEDETTO, ELAINA ANN (LCSW)
Entity type:Individual
Prefix:
First Name:ELAINA
Middle Name:ANN
Last Name:DIBENEDETTO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 SANDALWOOD DR
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10308-1848
Mailing Address - Country:US
Mailing Address - Phone:347-522-8672
Mailing Address - Fax:
Practice Address - Street 1:2336 RICHMOND RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10306-2346
Practice Address - Country:US
Practice Address - Phone:929-381-0689
Practice Address - Fax:718-962-7516
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-09
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0963321041C0700X
NY108514104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker