Basic Information
| Provider Information | |||||||||
| NPI: | 1356515514 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PELOSI | ||||||||
| FirstName: | LINDA | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | R-LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 290 SAGAMORE HILLS DR | ||||||||
| Address2: | PORT JEFFERSON STATION | ||||||||
| City: | PORT JEFFERSON STATION | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117763556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6318281670 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 220 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CENTER MORICHES | ||||||||
| State: | NY | ||||||||
| PostalCode: | 119343504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6318742700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2008 | ||||||||
| LastUpdateDate: | 04/18/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | R031781-1 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.