Provider Demographics
NPI:1265900526
Name:PRUDHOMME, RELANI (LCSW)
Entity type:Individual
Prefix:MS
First Name:RELANI
Middle Name:
Last Name:PRUDHOMME
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:RELANI
Other - Middle Name:MICHELLE
Other - Last Name:PRUDHOMME
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW, MSW
Mailing Address - Street 1:73 BUCK ST APT B
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:NY
Mailing Address - Zip Code:13617-1384
Mailing Address - Country:US
Mailing Address - Phone:315-212-1815
Mailing Address - Fax:
Practice Address - Street 1:73 BUCK ST APT B
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:NY
Practice Address - Zip Code:13617-1384
Practice Address - Country:US
Practice Address - Phone:315-212-1815
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-05
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY065968104100000X
NY0958151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00655803Medicaid