Provider Demographics
NPI:1548967771
Name:PALLONETTI, MICHAEL SR (CASAC-T)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:PALLONETTI
Suffix:SR
Gender:M
Credentials:CASAC-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 GLENRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:GLENVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12302-4523
Mailing Address - Country:US
Mailing Address - Phone:917-690-6059
Mailing Address - Fax:
Practice Address - Street 1:90-02 161ST STREET
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-3631
Practice Address - Country:US
Practice Address - Phone:718-520-1503
Practice Address - Fax:718-520-6460
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-08
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY39006101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)