Provider Demographics
NPI:1619479961
Name:PRISM PSYCHOTHERAPY LCSW PC
Entity Type:Organization
Organization Name:PRISM PSYCHOTHERAPY LCSW PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:E
Authorized Official - Last Name:PACOS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSWR
Authorized Official - Phone:845-656-2606
Mailing Address - Street 1:PO BOX 1196
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:NY
Mailing Address - Zip Code:10990-8196
Mailing Address - Country:US
Mailing Address - Phone:845-656-2606
Mailing Address - Fax:
Practice Address - Street 1:56 MAIN ST STE 3-5
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:NY
Practice Address - Zip Code:10990-1345
Practice Address - Country:US
Practice Address - Phone:845-656-2606
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-02
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty