Provider Demographics
NPI:1982741849
Name:CONVERTINO, ANITA (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:ANITA
Middle Name:
Last Name:CONVERTINO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:ANITA
Other - Middle Name:
Other - Last Name:DAYAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:312 ELM ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066-1414
Mailing Address - Country:US
Mailing Address - Phone:315-476-4050
Mailing Address - Fax:315-425-7268
Practice Address - Street 1:312 ELM ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-1414
Practice Address - Country:US
Practice Address - Phone:315-476-4050
Practice Address - Fax:315-425-7268
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2009-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0438231103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBB1609Medicare ID - Type Unspecified