Provider Demographics
NPI:1952847279
Name:HENNESSY, THERESA (LCSW-R)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:
Last Name:HENNESSY
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:339 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:MENANDS
Mailing Address - State:NY
Mailing Address - Zip Code:12077
Mailing Address - Country:US
Mailing Address - Phone:518-465-5204
Mailing Address - Fax:518-463-8051
Practice Address - Street 1:339 BROADWAY
Practice Address - Street 2:
Practice Address - City:MENANDS
Practice Address - State:NY
Practice Address - Zip Code:12204-2708
Practice Address - Country:US
Practice Address - Phone:518-465-5204
Practice Address - Fax:518-463-8051
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-10
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY14-1410352Medicaid