Provider Demographics
NPI:1952847279
Name:HENNESSY, THERESA (LCSW-R)
Entity type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:
Last Name:HENNESSY
Suffix:
Gender:F
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 1:200 DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:DELMAR
Mailing Address - State:NY
Mailing Address - Zip Code:12054-1227
Mailing Address - Country:US
Mailing Address - Phone:518-478-9936
Mailing Address - Fax:518-439-0267
Practice Address - Street 1:200 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:DELMAR
Practice Address - State:NY
Practice Address - Zip Code:12054-1227
Practice Address - Country:US
Practice Address - Phone:518-478-9936
Practice Address - Fax:518-439-0267
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-10
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0584761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY14-1410352Medicaid