Basic Information
| Provider Information | |||||||||
| NPI: | 1003966623 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PELTON | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | CLAIRE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSWR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19 STANWOOD RD | ||||||||
| Address2: | |||||||||
| City: | MOUNT KISCO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105494206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9149625593 | ||||||||
| FaxNumber: | 9149625599 | ||||||||
| Practice Location | |||||||||
| Address1: | 280 N BEDFORD RD STE 203 | ||||||||
| Address2: | |||||||||
| City: | MOUNT KISCO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105491147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9145236852 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2007 | ||||||||
| LastUpdateDate: | 10/20/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | R049256-1 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 140049256NY01 | 01 | NY | ANTHEM | OTHER | 200747 | 01 | NY | HEALTHNET | OTHER |