Healthcare Provider Details

I. General information

NPI: 1306918792
Provider Name (Legal Business Name): PETER PERSOFF LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 FENN ST
PITTSFIELD MA
01201-5269
US

IV. Provider business mailing address

26 LAKEVIEW CIR
HINSDALE MA
01235-9251
US

V. Phone/Fax

Practice location:
  • Phone: 413-496-9671
  • Fax:
Mailing address:
  • Phone: 413-655-2071
  • Fax: 413-655-8833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number111772
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberPR012213-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: