=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861763971
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | YANET M PENA-TIRADO LMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/20/2012
-----------------------------------------------------
Last Update Date | 01/20/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12 FILLMORE DR
-----------------------------------------------------
City | STONY POINT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10980-3705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-947-4674
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12 FILLMORE DRIVE
-----------------------------------------------------
City | STONY POINT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10980-3705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-608-6033
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 7000981
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041S0200X
-----------------------------------------------------
Taxonomy Name | School Social Worker
-----------------------------------------------------
License Number | 414996101
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------