Provider Demographics
NPI:1003121443
Name:SUTRISNO, MARIA W (LMSW)
Entity Type:Individual
Prefix:MS
First Name:MARIA
Middle Name:W
Last Name:SUTRISNO
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7502 RIDGE BLVD
Mailing Address - Street 2:APT C8
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-2942
Mailing Address - Country:US
Mailing Address - Phone:515-441-6154
Mailing Address - Fax:
Practice Address - Street 1:180 LIVINGSTON ST
Practice Address - Street 2:SUITE 306
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-5861
Practice Address - Country:US
Practice Address - Phone:718-625-4055
Practice Address - Fax:718-625-3931
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-10
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0814761104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker