Basic Information
| Provider Information | |||||||||
| NPI: | 1477115038 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CORACI | ||||||||
| FirstName: | CHRISTINE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LONGO | ||||||||
| OtherFirstName: | CHRISTINE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LMSW | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1413 STONY BROOK RD | ||||||||
| Address2: | |||||||||
| City: | STONY BROOK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117902214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314440101 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1413 STONY BROOK RD | ||||||||
| Address2: | |||||||||
| City: | STONY BROOK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117902214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314440101 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2019 | ||||||||
| LastUpdateDate: | 07/03/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 099534 | NY | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.