Provider Demographics
NPI:1851905889
Name:PANSA-AD, MALISSA (LMSW)
Entity Type:Individual
Prefix:
First Name:MALISSA
Middle Name:
Last Name:PANSA-AD
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3208 36TH AVE APT 3F
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11106-2208
Mailing Address - Country:US
Mailing Address - Phone:732-910-6737
Mailing Address - Fax:
Practice Address - Street 1:96 W HOUSTON ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10012-2553
Practice Address - Country:US
Practice Address - Phone:833-775-6252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-08
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY109621104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker