Provider Demographics
NPI:1972605475
Name:PRUSSIN, RICHARD MICHAEL (LCSW)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:MICHAEL
Last Name:PRUSSIN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 W GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:BALDWINSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13027-1105
Mailing Address - Country:US
Mailing Address - Phone:315-638-0988
Mailing Address - Fax:315-251-2603
Practice Address - Street 1:12 W GENESEE ST
Practice Address - Street 2:
Practice Address - City:BALDWINSVILLE
Practice Address - State:NY
Practice Address - Zip Code:13027-1105
Practice Address - Country:US
Practice Address - Phone:315-638-0988
Practice Address - Fax:315-251-2603
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-04
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPR014595-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY11239539OtherCAQH
NY392979OtherMVP
NY146679OtherVALUEOPTIONS
NYRA7966Medicare PIN
NY146679OtherVALUEOPTIONS