Provider Demographics
NPI:1285137133
Name:SIRIZZOTTI, LEA
Entity type:Individual
Prefix:
First Name:LEA
Middle Name:
Last Name:SIRIZZOTTI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LEA
Other - Middle Name:
Other - Last Name:SUSCA/KOPELMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:MANORVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11949-3156
Mailing Address - Country:US
Mailing Address - Phone:631-566-0646
Mailing Address - Fax:
Practice Address - Street 1:212 W MAIN ST
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901
Practice Address - Country:US
Practice Address - Phone:631-369-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-16
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008460101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health