Provider Demographics
NPI:1063446052
Name:SESACK, EDWARD D (LCSW)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:D
Last Name:SESACK
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 SAINT JOHN ST
Mailing Address - Street 2:
Mailing Address - City:SCHUYLKILL HAVEN
Mailing Address - State:PA
Mailing Address - Zip Code:17972-1652
Mailing Address - Country:US
Mailing Address - Phone:570-385-8490
Mailing Address - Fax:570-385-8491
Practice Address - Street 1:13 SAINT JOHN ST
Practice Address - Street 2:
Practice Address - City:SCHUYLKILL HAVEN
Practice Address - State:PA
Practice Address - Zip Code:17972-1652
Practice Address - Country:US
Practice Address - Phone:570-385-8490
Practice Address - Fax:570-385-8491
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0133001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA040391Medicare ID - Type Unspecified