Provider Demographics
NPI:1619077153
Name:WILBUR-HARRIS, PENNY (LCSW)
Entity Type:Individual
Prefix:MS
First Name:PENNY
Middle Name:
Last Name:WILBUR-HARRIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 BROOKFIELD LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11720-1444
Mailing Address - Country:US
Mailing Address - Phone:631-553-8469
Mailing Address - Fax:
Practice Address - Street 1:15 BROOKFIELD LN
Practice Address - Street 2:
Practice Address - City:SOUTH SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11720-1444
Practice Address - Country:US
Practice Address - Phone:631-553-8469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-24
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0273331041C0700X
NY1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY145126OtherVALUE OPTIONS
NYIP322152OtherEMPIRE BC/BS
MO11238224OtherCAQH
TX4281184OtherAETNA
CTP75660OtherOXFORD