Provider Demographics
NPI:1093319576
Name:COME TO THE TABLE COUNSELING LCSW
Entity Type:Organization
Organization Name:COME TO THE TABLE COUNSELING LCSW
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:M
Authorized Official - Last Name:PERUSSE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-R
Authorized Official - Phone:315-335-9727
Mailing Address - Street 1:4097 WILSON RD E
Mailing Address - Street 2:
Mailing Address - City:TABERG
Mailing Address - State:NY
Mailing Address - Zip Code:13471-2037
Mailing Address - Country:US
Mailing Address - Phone:315-335-9727
Mailing Address - Fax:
Practice Address - Street 1:40 MAIN ST LOWR
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NY
Practice Address - Zip Code:13316-1302
Practice Address - Country:US
Practice Address - Phone:315-335-9727
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-25
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05560238Medicaid