Provider Demographics
NPI:1376609123
Name:MINUCCI, PETER JR (LCSW)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:
Last Name:MINUCCI
Suffix:JR
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:187 DROMS RD
Mailing Address - Street 2:
Mailing Address - City:SCOTIA
Mailing Address - State:NY
Mailing Address - Zip Code:12302-9739
Mailing Address - Country:US
Mailing Address - Phone:518-384-0224
Mailing Address - Fax:
Practice Address - Street 1:116 S LAKE AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-3371
Practice Address - Country:US
Practice Address - Phone:518-465-8728
Practice Address - Fax:518-436-3576
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR03407211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBB9634Medicare ID - Type UnspecifiedSOCIAL WORKER