Provider Demographics
NPI:1285661322
Name:SPANO, THERESA L (LCSW-R)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:L
Last Name:SPANO
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:TERRI
Other - Middle Name:L
Other - Last Name:SPANO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:121 OLD MOUNTAIN RD N
Mailing Address - Street 2:
Mailing Address - City:NYACK
Mailing Address - State:NY
Mailing Address - Zip Code:10960-1207
Mailing Address - Country:US
Mailing Address - Phone:914-633-2990
Mailing Address - Fax:
Practice Address - Street 1:100 MAMARONECK AVE
Practice Address - Street 2:
Practice Address - City:MAMARONECK
Practice Address - State:NY
Practice Address - Zip Code:10543-3753
Practice Address - Country:US
Practice Address - Phone:914-633-2990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0521881-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY339342OtherMHN PRACTIONER ID #
NY339342OtherMHN PRACTIONER ID #