Provider Demographics
NPI:1225106792
Name:RISENER, ANITA G (LCSW-R)
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:G
Last Name:RISENER
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 MERRIMAC CT
Mailing Address - Street 2:
Mailing Address - City:CORAM
Mailing Address - State:NY
Mailing Address - Zip Code:11727-1632
Mailing Address - Country:US
Mailing Address - Phone:631-331-8595
Mailing Address - Fax:
Practice Address - Street 1:3293 RT 112
Practice Address - Street 2:BLG 8 SUITE 8
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-1432
Practice Address - Country:US
Practice Address - Phone:631-331-8595
Practice Address - Fax:631-331-8595
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0252261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY120416OtherVYTRA PROVIDER #