Provider Demographics
NPI:1801874607
Name:PENN, MICHAEL R (LCSW)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:R
Last Name:PENN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 W 72ND ST
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023-2817
Mailing Address - Country:US
Mailing Address - Phone:212-579-2052
Mailing Address - Fax:212-864-1172
Practice Address - Street 1:260 W 72ND ST
Practice Address - Street 2:SUITE 1B
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10023-2817
Practice Address - Country:US
Practice Address - Phone:212-579-2052
Practice Address - Fax:212-864-1172
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0411711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN55071Medicare ID - Type Unspecified