1114053543 NPI number — MRS. LUANN MONGIELLO ESEN LCSW BCD

Table of content: MRS. LUANN MONGIELLO ESEN LCSW BCD (NPI 1114053543)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114053543 NPI number — MRS. LUANN MONGIELLO ESEN LCSW BCD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ESEN
Provider First Name:
LUANN
Provider Middle Name:
MONGIELLO
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW BCD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114053543
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
245 HIDDEN POND PATH
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WADING RIVER
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11792
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-428-3019
Provider Business Mailing Address Fax Number:
631-929-0182

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3771 NESCONSET HWY
Provider Second Line Business Practice Location Address:
SUITE 208A
Provider Business Practice Location Address City Name:
CENTEREACH
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11720
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-428-3019
Provider Business Practice Location Address Fax Number:
631-929-0182
Provider Enumeration Date:
02/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  R0528361 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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