Provider Demographics
NPI:1396260857
Name:CESTRO, MELISSA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:CESTRO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2565 HARVARD LN
Mailing Address - Street 2:
Mailing Address - City:SEAFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11783-3528
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2565 HARVARD LANE
Practice Address - Street 2:
Practice Address - City:SEAFORD
Practice Address - State:NY
Practice Address - Zip Code:11783
Practice Address - Country:US
Practice Address - Phone:516-785-8303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-07
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY085648-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY$$$$$$$$$Medicaid