Healthcare Provider Details

I. General information

NPI: 1538155189
Provider Name (Legal Business Name): ROBERT PENASKOVIC MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2005
Last Update Date: 08/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1517 FRANKLIN AVE 205
MINEOLA NY
11501-4804
US

IV. Provider business mailing address

1517 FRANKLIN AVE 205
MINEOLA NY
11501-4804
US

V. Phone/Fax

Practice location:
  • Phone: 516-746-3203
  • Fax:
Mailing address:
  • Phone: 516-746-3203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberPRO14573-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: