Provider Demographics
NPI:1851654180
Name:PETHANI, ASHISH (LCSW)
Entity Type:Individual
Prefix:
First Name:ASHISH
Middle Name:
Last Name:PETHANI
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 1:50 RUSSELL ST
Mailing Address - Street 2:
Mailing Address - City:ROSLYN HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11577-1342
Mailing Address - Country:US
Mailing Address - Phone:718-268-9595
Mailing Address - Fax:718-268-9528
Practice Address - Street 1:7558 113TH ST
Practice Address - Street 2:SUITE 1A
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-2204
Practice Address - Country:US
Practice Address - Phone:718-268-9595
Practice Address - Fax:718-268-9528
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-21
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0795271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY079527OtherLICENSE #