Provider Demographics
NPI:1700478419
Name:PEARSON, RUPERT GRANTLEY (LMSW)
Entity Type:Individual
Prefix:
First Name:RUPERT
Middle Name:GRANTLEY
Last Name:PEARSON
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4531 HILL AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10466-1025
Mailing Address - Country:US
Mailing Address - Phone:917-406-4670
Mailing Address - Fax:
Practice Address - Street 1:4531 HILL AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10466-1025
Practice Address - Country:US
Practice Address - Phone:917-406-4670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-04
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY111138-011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical