Provider Demographics
NPI:1043882046
Name:DRAG, PENNY LYNN (LMSW)
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:LYNN
Last Name:DRAG
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 1:4535 SOUTHWESTERN BLVD STE 706A
Mailing Address - Street 2:
Mailing Address - City:HAMBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14075-1870
Mailing Address - Country:US
Mailing Address - Phone:716-449-0494
Mailing Address - Fax:
Practice Address - Street 1:4535 SOUTHWESTERN BLVD STE 706A
Practice Address - Street 2:
Practice Address - City:HAMBURG
Practice Address - State:NY
Practice Address - Zip Code:14075-1870
Practice Address - Country:US
Practice Address - Phone:716-449-0494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-11
Last Update Date:2021-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101YM0800X
NY078343104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health