Healthcare Provider Details

I. General information

NPI: 1285661322
Provider Name (Legal Business Name): THERESA L. SPANO LCSW-R
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TERRI L. SPANO

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 07/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MAMARONECK AVE
MAMARONECK NY
10543-3753
US

IV. Provider business mailing address

121 OLD MOUNTAIN RD N
NYACK NY
10960-1207
US

V. Phone/Fax

Practice location:
  • Phone: 914-633-2990
  • Fax:
Mailing address:
  • Phone: 914-633-2990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR0521881-1
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier339342
Identifier TypeOTHER
Identifier StateNY
Identifier IssuerMHN PRACTIONER ID #

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: