Provider Demographics
NPI:1649210527
Name:CALDERAZZO, PENNY HENRIETTA (LCSW)
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:HENRIETTA
Last Name:CALDERAZZO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:HENRIETTA
Other - Middle Name:PENNY
Other - Last Name:CALDERAZZO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:516 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-3015
Mailing Address - Country:US
Mailing Address - Phone:607-592-5746
Mailing Address - Fax:
Practice Address - Street 1:516 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-3015
Practice Address - Country:US
Practice Address - Phone:607-592-5746
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0603851104100000X
NY0701611104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
P87582Medicare UPIN
NYDD5387Medicare ID - Type Unspecified