Provider Demographics
NPI:1033295498
Name:COYLE FAMULARO, TERRI ANNE (LCSW)
Entity type:Individual
Prefix:MS
First Name:TERRI
Middle Name:ANNE
Last Name:COYLE FAMULARO
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 1:1908 BROOKHAVEN AVE
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-3626
Mailing Address - Country:US
Mailing Address - Phone:718-869-8400
Mailing Address - Fax:718-869-8405
Practice Address - Street 1:1908 BROOKHAVEN AVE
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-3626
Practice Address - Country:US
Practice Address - Phone:718-869-8400
Practice Address - Fax:718-869-8405
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-28
Last Update Date:2018-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR054801-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ09983Medicare UPIN