Provider Demographics
NPI:1407007586
Name:FEVOLA, TANYA JENNIFER (LCSW-R)
Entity type:Individual
Prefix:MRS
First Name:TANYA
Middle Name:JENNIFER
Last Name:FEVOLA
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:283 COMMACK RD
Mailing Address - Street 2:SUITE #100
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-6021
Mailing Address - Country:US
Mailing Address - Phone:631-462-1032
Mailing Address - Fax:
Practice Address - Street 1:283 COMMACK RD
Practice Address - Street 2:SUITE #100
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-6021
Practice Address - Country:US
Practice Address - Phone:631-462-1032
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-07
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR07147811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical