Healthcare Provider Details

I. General information

NPI: 1881811826
Provider Name (Legal Business Name): PETER WATROUS LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 01/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 PINE WEST PLZ STE 508
ALBANY NY
12205-5587
US

IV. Provider business mailing address

475 DEPOT RD
DUANESBURG NY
12056-2503
US

V. Phone/Fax

Practice location:
  • Phone: 518-452-4232
  • Fax: 518-452-4233
Mailing address:
  • Phone: 518-895-8861
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR016053-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: