Provider Demographics
NPI:1578697900
Name:O'HERRON, PETER R (LCSW)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:R
Last Name:O'HERRON
Suffix:
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 1:308 W SHORE RD
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11769-2170
Mailing Address - Country:US
Mailing Address - Phone:631-589-8937
Mailing Address - Fax:
Practice Address - Street 1:65 PARK AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-7359
Practice Address - Country:US
Practice Address - Phone:631-665-0229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY058540104100000X, 1041C0700X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP34799Medicare UPIN