Provider Demographics
NPI:1790420164
Name:PENNACCHIA, STEPHANIE (LCSW)
Entity type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:
Last Name:PENNACCHIA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1789 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10035-4537
Mailing Address - Country:US
Mailing Address - Phone:646-820-7610
Mailing Address - Fax:
Practice Address - Street 1:1789 MADISON AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10035-4537
Practice Address - Country:US
Practice Address - Phone:646-820-7610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-30
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY092232-011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY092232-01OtherUNIVERSITY OF THE STATE OF NY EDUCATION DEPARTMENT OFFICE OF THE PROFESSIONS