Provider Demographics
NPI:1861763971
Name:PENA-TIRADO, YANET M (LMSW)
Entity type:Individual
Prefix:MRS
First Name:YANET
Middle Name:M
Last Name:PENA-TIRADO
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 1:12 FILLMORE DRIVE
Mailing Address - Street 2:
Mailing Address - City:STONY POINT
Mailing Address - State:NY
Mailing Address - Zip Code:10980-3705
Mailing Address - Country:US
Mailing Address - Phone:917-608-6033
Mailing Address - Fax:
Practice Address - Street 1:12 FILLMORE DR
Practice Address - Street 2:
Practice Address - City:STONY POINT
Practice Address - State:NY
Practice Address - Zip Code:10980-3705
Practice Address - Country:US
Practice Address - Phone:845-947-4674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-20
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY70009811041C0700X
NY4149961011041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY7000981OtherNYS LICENSED MASTER SOCIAL WORKER