Provider Demographics
NPI:1881811826
Name:WATROUS, PETER (LCSW)
Entity type:Individual
Prefix:MR
First Name:PETER
Middle Name:
Last Name:WATROUS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 DEPOT RD
Mailing Address - Street 2:
Mailing Address - City:DUANESBURG
Mailing Address - State:NY
Mailing Address - Zip Code:12056-2503
Mailing Address - Country:US
Mailing Address - Phone:518-895-8861
Mailing Address - Fax:
Practice Address - Street 1:5 PINE WEST PLZ STE 508
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-5587
Practice Address - Country:US
Practice Address - Phone:518-452-4232
Practice Address - Fax:518-452-4233
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2008-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR016053-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYR016053-1OtherLCSW
NY11741088OtherCAQH
NYRB6167Medicare PIN