Provider Demographics
NPI:1295010650
Name:CORMACK, LESA MAY (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:LESA
Middle Name:MAY
Last Name:CORMACK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:LESA
Other - Middle Name:MAY
Other - Last Name:TRAORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BA
Mailing Address - Street 1:777 SEAVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-3409
Mailing Address - Country:US
Mailing Address - Phone:718-667-2790
Mailing Address - Fax:
Practice Address - Street 1:777 SEAVIEW AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-3409
Practice Address - Country:US
Practice Address - Phone:718-667-2790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-18
Last Update Date:2023-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY095508-011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical