Provider Demographics
NPI:1861608325
Name:PELLEGRINO, THERESA ANN
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:ANN
Last Name:PELLEGRINO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 LOCKWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11735-4510
Mailing Address - Country:US
Mailing Address - Phone:516-249-7480
Mailing Address - Fax:
Practice Address - Street 1:77 LOCKWOOD AVE
Practice Address - Street 2:
Practice Address - City:FARMINGDALE
Practice Address - State:NY
Practice Address - Zip Code:11735-4510
Practice Address - Country:US
Practice Address - Phone:516-249-7480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000263101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health