Provider Demographics
NPI:1578172391
Name:ALTAMIRANO-FARRELL, SELENE (LMSW)
Entity Type:Individual
Prefix:
First Name:SELENE
Middle Name:
Last Name:ALTAMIRANO-FARRELL
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3780 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:STONE RIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:12484-5603
Mailing Address - Country:US
Mailing Address - Phone:845-663-1169
Mailing Address - Fax:
Practice Address - Street 1:3780 MAIN ST
Practice Address - Street 2:
Practice Address - City:STONE RIDGE
Practice Address - State:NY
Practice Address - Zip Code:12484-5603
Practice Address - Country:US
Practice Address - Phone:718-986-7470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-28
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101700104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker