Provider Demographics
NPI:1407883408
Name:PANKEN, RUTH
Entity Type:Individual
Prefix:
First Name:RUTH
Middle Name:
Last Name:PANKEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RUTH
Other - Middle Name:
Other - Last Name:PANKEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:271 BAYVIEW AVENUE
Mailing Address - Street 2:
Mailing Address - City:MERRICK
Mailing Address - State:NY
Mailing Address - Zip Code:11566
Mailing Address - Country:US
Mailing Address - Phone:516-623-8518
Mailing Address - Fax:516-378-0720
Practice Address - Street 1:271 BAYVIEW AVE
Practice Address - Street 2:
Practice Address - City:MERRICK
Practice Address - State:NY
Practice Address - Zip Code:11566-4729
Practice Address - Country:US
Practice Address - Phone:516-623-8518
Practice Address - Fax:516-378-0720
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR032173-1101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN79881Medicare ID - Type Unspecified