Healthcare Provider Details

I. General information

NPI: 1083592513
Provider Name (Legal Business Name): LAUREN GISELA PETOSA LMSW, CTRI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2025
Last Update Date: 10/08/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 S PARK ST
CAMBRIDGE NY
12816
US

IV. Provider business mailing address

P.O. BOX 757
TANNERSVILLE NY
12485
US

V. Phone/Fax

Practice location:
  • Phone: 518-677-8527
  • Fax:
Mailing address:
  • Phone: 518-322-0567
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number14228723-350
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number130421
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: