Provider Demographics
NPI:1932251543
Name:SEPULVEDA, CONNIE (LCSW)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:SEPULVEDA
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 1:775 BONNIE DR
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-4522
Mailing Address - Country:US
Mailing Address - Phone:516-546-7568
Mailing Address - Fax:
Practice Address - Street 1:100 N VILLAGE AVE
Practice Address - Street 2:SUITE 39
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-3767
Practice Address - Country:US
Practice Address - Phone:516-546-7568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029047-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYVALUE OPTIONSOther145717