Basic Information
| Provider Information | |||||||||
| NPI: | 1326364084 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEGRANDE | ||||||||
| FirstName: | DANA | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CALIXTE | ||||||||
| OtherFirstName: | DANA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LCSW R | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 700 FULTON ST APT M3 | ||||||||
| Address2: | |||||||||
| City: | FARMINGDALE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117353447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5163025645 | ||||||||
| FaxNumber: | 6316472058 | ||||||||
| Practice Location | |||||||||
| Address1: | 1444 5TH AVE | ||||||||
| Address2: | |||||||||
| City: | BAY SHORE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117064147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6316500143 | ||||||||
| FaxNumber: | 6316472058 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2010 | ||||||||
| LastUpdateDate: | 02/25/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 079547 | NY | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 080869 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 00079547 | 05 | NY | MEDICAID |