Provider Demographics
NPI:1164719555
Name:WELLER, PENNY SUZETTE (LCSW-R)
Entity Type:Individual
Prefix:MS
First Name:PENNY
Middle Name:SUZETTE
Last Name:WELLER
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:MS
Other - First Name:PENNY
Other - Middle Name:SUZETTE
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW-R
Mailing Address - Street 1:8 TILSIT WAY
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:NY
Mailing Address - Zip Code:14580-4705
Mailing Address - Country:US
Mailing Address - Phone:585-752-0198
Mailing Address - Fax:
Practice Address - Street 1:8 TILSIT WAY
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:NY
Practice Address - Zip Code:14580-4705
Practice Address - Country:US
Practice Address - Phone:585-752-0198
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-06
Last Update Date:2011-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0502051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical