Provider Demographics
NPI:1205977972
Name:PENK, JAMES E (LCSW-R)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:E
Last Name:PENK
Suffix:
Gender:M
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 1:3484 ROSENDALE RD
Mailing Address - Street 2:
Mailing Address - City:NISKAYUNA
Mailing Address - State:NY
Mailing Address - Zip Code:12309-1514
Mailing Address - Country:US
Mailing Address - Phone:518-783-5969
Mailing Address - Fax:
Practice Address - Street 1:1311 UNION ST.
Practice Address - Street 2:
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12308
Practice Address - Country:US
Practice Address - Phone:518-374-6263
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR-035359-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01458644Medicaid