Provider Demographics
NPI:1780947309
Name:PROVENZANO, ALYSSA MARIE (LMSW)
Entity type:Individual
Prefix:MISS
First Name:ALYSSA
Middle Name:MARIE
Last Name:PROVENZANO
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6637 YELLOWSTONE BLVD
Mailing Address - Street 2:APT. 4A
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-2544
Mailing Address - Country:US
Mailing Address - Phone:917-579-3379
Mailing Address - Fax:
Practice Address - Street 1:1051 RIVERSIDE DR
Practice Address - Street 2:SUITE 1701
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-1007
Practice Address - Country:US
Practice Address - Phone:212-543-2958
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-19
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY086452-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical