Provider Demographics
NPI:1871331736
Name:IMMEDIATO, EMMA RAE (MSW)
Entity type:Individual
Prefix:
First Name:EMMA
Middle Name:RAE
Last Name:IMMEDIATO
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 AGATHA DR
Mailing Address - Street 2:
Mailing Address - City:PLAINVIEW
Mailing Address - State:NY
Mailing Address - Zip Code:11803-5401
Mailing Address - Country:US
Mailing Address - Phone:516-729-3405
Mailing Address - Fax:
Practice Address - Street 1:350 JERICHO TPKE STE 103
Practice Address - Street 2:
Practice Address - City:JERICHO
Practice Address - State:NY
Practice Address - Zip Code:11753-1317
Practice Address - Country:US
Practice Address - Phone:516-339-5373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-16
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY095074104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker