Provider Demographics
NPI:1205572088
Name:NEVILLE, IAN R (MHC-LP)
Entity type:Individual
Prefix:MR
First Name:IAN
Middle Name:R
Last Name:NEVILLE
Suffix:
Gender:M
Credentials:MHC-LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 CLENT RD APT 1D
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK PLAZA
Mailing Address - State:NY
Mailing Address - Zip Code:11021-3493
Mailing Address - Country:US
Mailing Address - Phone:585-469-3397
Mailing Address - Fax:
Practice Address - Street 1:535 S OYSTER BAY RD
Practice Address - Street 2:
Practice Address - City:PLAINVIEW
Practice Address - State:NY
Practice Address - Zip Code:11803-3310
Practice Address - Country:US
Practice Address - Phone:516-818-8383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-05
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP114348101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP114348OtherNEW YORK DEPARTMENT OF EDUCATION