Provider Demographics
NPI:1871898668
Name:DEFALCO, GINA (LMSW)
Entity type:Individual
Prefix:MRS
First Name:GINA
Middle Name:
Last Name:DEFALCO
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:229 N PINE ST
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-2812
Mailing Address - Country:US
Mailing Address - Phone:516-528-5822
Mailing Address - Fax:
Practice Address - Street 1:229 N PINE ST
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-2812
Practice Address - Country:US
Practice Address - Phone:516-528-5822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-25
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY073927-1101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor