Provider Demographics
NPI:1528194040
Name:HETZER, LARAINE DE BLONDE (MSW LDCSW R)
Entity Type:Individual
Prefix:MRS
First Name:LARAINE
Middle Name:DE BLONDE
Last Name:HETZER
Suffix:
Gender:F
Credentials:MSW LDCSW R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 SATTERLEE PLACE
Mailing Address - Street 2:
Mailing Address - City:WAPPINGERS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12590-2625
Mailing Address - Country:US
Mailing Address - Phone:845-298-8070
Mailing Address - Fax:845-462-3310
Practice Address - Street 1:12 SATTERLEE PLACE
Practice Address - Street 2:
Practice Address - City:WAPPINGERS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12590-2625
Practice Address - Country:US
Practice Address - Phone:845-298-8070
Practice Address - Fax:845-462-3310
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY03844311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02261392Medicaid
NYN40302Medicare ID - Type Unspecified