Provider Demographics
NPI:1407634694
Name:NOVA, ERASTO (LMSW)
Entity Type:Individual
Prefix:
First Name:ERASTO
Middle Name:
Last Name:NOVA
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1352 3RD ST
Mailing Address - Street 2:
Mailing Address - City:RENSSELAER
Mailing Address - State:NY
Mailing Address - Zip Code:12144-1822
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:700 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-1404
Practice Address - Country:US
Practice Address - Phone:518-475-6299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-19
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY119633-011041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchoolGroup - Single Specialty