Provider Demographics
NPI:1386139681
Name:SIMONETTI, LANA MARIE (BA, MS)
Entity type:Individual
Prefix:MS
First Name:LANA
Middle Name:MARIE
Last Name:SIMONETTI
Suffix:
Gender:F
Credentials:BA, MS
Other - Prefix:MS
Other - First Name:LANA
Other - Middle Name:MARIE
Other - Last Name:SIMONETTI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BA, MS
Mailing Address - Street 1:3552 SUMMER DR
Mailing Address - Street 2:
Mailing Address - City:WANTAGH
Mailing Address - State:NY
Mailing Address - Zip Code:11793-2728
Mailing Address - Country:US
Mailing Address - Phone:516-557-6749
Mailing Address - Fax:516-826-6262
Practice Address - Street 1:2631 MERRICK RD STE 302
Practice Address - Street 2:
Practice Address - City:BELLMORE
Practice Address - State:NY
Practice Address - Zip Code:11710-5784
Practice Address - Country:US
Practice Address - Phone:516-590-7575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-28
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY$$$$$$$$$Medicaid