Provider Demographics
NPI:1023340353
Name:HERMITT, PETA GAYE (LCSW, CASAC)
Entity type:Individual
Prefix:MISS
First Name:PETA GAYE
Middle Name:
Last Name:HERMITT
Suffix:
Gender:F
Credentials:LCSW, CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 POLY PL
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-7104
Mailing Address - Country:US
Mailing Address - Phone:718-836-6600
Mailing Address - Fax:718-439-4340
Practice Address - Street 1:40 FLATBUSH AVENUE EXT
Practice Address - Street 2:8TH FLOOR
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-2903
Practice Address - Country:US
Practice Address - Phone:718-439-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-11
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY22761101YA0400X
NY0835981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY22761OtherCASAC-T