Provider Demographics
NPI:1386377737
Name:POPOLO, MICHELLE ANDRIENNE (LMSW)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:ANDRIENNE
Last Name:POPOLO
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:ANDRIENNE
Other - Last Name:CVETKOVSKI-POPOLO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMSW
Mailing Address - Street 1:PO BOX 12
Mailing Address - Street 2:
Mailing Address - City:MIDDLE ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:11953-0012
Mailing Address - Country:US
Mailing Address - Phone:631-924-0008
Mailing Address - Fax:
Practice Address - Street 1:35 LONGWOOD RD
Practice Address - Street 2:
Practice Address - City:MIDDLE ISLAND
Practice Address - State:NY
Practice Address - Zip Code:11953-2045
Practice Address - Country:US
Practice Address - Phone:631-924-0008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-05
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY115074104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker