Provider Demographics
NPI:1841585122
Name:AMMENDOLA, PAUL (LCSW)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:AMMENDOLA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 W MERRICK RD
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11520-3873
Mailing Address - Country:US
Mailing Address - Phone:516-868-3030
Mailing Address - Fax:516-868-3374
Practice Address - Street 1:105 N CAMBRIDGE ST
Practice Address - Street 2:
Practice Address - City:MALVERNE
Practice Address - State:NY
Practice Address - Zip Code:11565-2151
Practice Address - Country:US
Practice Address - Phone:516-868-3030
Practice Address - Fax:516-868-3374
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-14
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
NY085424104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker