Provider Demographics
NPI:1558784751
Name:ANGELILLO, ALYSSA ROSE (LCSW, CASAC)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:ROSE
Last Name:ANGELILLO
Suffix:
Gender:F
Credentials:LCSW, CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 BEDFORD AVE
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-3808
Mailing Address - Country:US
Mailing Address - Phone:516-747-5644
Mailing Address - Fax:516-747-2556
Practice Address - Street 1:110 MAIN ST
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-4000
Practice Address - Country:US
Practice Address - Phone:516-747-5644
Practice Address - Fax:516-747-2556
Is Sole Proprietor?:No
Enumeration Date:2014-01-24
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY24178101YA0400X
NY0882941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1558784751Medicaid