Provider Demographics
NPI:1124132832
Name:MANDRA STALLONE, GAIL I (LCSW)
Entity type:Individual
Prefix:
First Name:GAIL
Middle Name:I
Last Name:MANDRA STALLONE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 BROADHOLLOW RD
Mailing Address - Street 2:SUITE 228
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-3669
Mailing Address - Country:US
Mailing Address - Phone:631-827-8200
Mailing Address - Fax:631-501-1103
Practice Address - Street 1:445 BROADHOLLOW RD
Practice Address - Street 2:SUITE 228
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-3669
Practice Address - Country:US
Practice Address - Phone:631-827-8200
Practice Address - Fax:631-501-1103
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053058-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA300062673OtherMEDICARE PTAN
NY0039339Medicaid