Provider Demographics
NPI:1801990536
Name:ST JOHN, VIRGINIA E (LCSW)
Entity type:Individual
Prefix:MS
First Name:VIRGINIA
Middle Name:E
Last Name:ST JOHN
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 1:790 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11793
Mailing Address - Country:US
Mailing Address - Phone:631-427-3700
Mailing Address - Fax:631-427-4268
Practice Address - Street 1:66 NEWTOWN LANE
Practice Address - Street 2:
Practice Address - City:EAST HAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11937
Practice Address - Country:US
Practice Address - Phone:631-234-3344
Practice Address - Fax:631-324-6109
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0299931104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN71831Medicare ID - Type Unspecified