Healthcare Provider Details

I. General information

NPI: 1033476882
Provider Name (Legal Business Name): DEANNA LONGWELL SARGENT LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MRS. DEANNA SARGENT

II. Dates (important events)

Enumeration Date: 04/18/2012
Last Update Date: 04/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1068 HUDSON AVE
STILLWATER NY
12170-3432
US

IV. Provider business mailing address

20 MILTON HEIGHTS BLVD
BALLSTON SPA NY
12020-2672
US

V. Phone/Fax

Practice location:
  • Phone: 518-373-6139
  • Fax:
Mailing address:
  • Phone: 518-884-0473
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number055777-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number079556-1
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number903113
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: