Provider Demographics
NPI:1316511868
Name:RENE, MICHAEL (LMSW)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:RENE
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 MACDONALD AVE
Mailing Address - Street 2:
Mailing Address - City:BELLPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11713-1727
Mailing Address - Country:US
Mailing Address - Phone:631-466-2218
Mailing Address - Fax:
Practice Address - Street 1:350 MARTHA AVE
Practice Address - Street 2:
Practice Address - City:BELLPORT
Practice Address - State:NY
Practice Address - Zip Code:11713-1525
Practice Address - Country:US
Practice Address - Phone:631-286-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-19
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY109633-01104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker