Provider Demographics
NPI:1831254200
Name:CHIESA, MYRNA M (LCSW)
Entity type:Individual
Prefix:MRS
First Name:MYRNA
Middle Name:M
Last Name:CHIESA
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 1:485 EASTON ST
Mailing Address - Street 2:
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-6154
Mailing Address - Country:US
Mailing Address - Phone:631-585-7858
Mailing Address - Fax:631-585-7858
Practice Address - Street 1:485 EASTON ST
Practice Address - Street 2:
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-6154
Practice Address - Country:US
Practice Address - Phone:631-585-7858
Practice Address - Fax:631-585-7858
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR30964-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02026355Medicaid
NY02026355Medicaid
NYNO9941Medicare UPIN