Basic Information
| Provider Information | |||||||||
| NPI: | 1386978302 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PURRO | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19 GREENRIDGE AVE | ||||||||
| Address2: | |||||||||
| City: | WHITE PLAINS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 106051201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9149651109 | ||||||||
| FaxNumber: | 9149659705 | ||||||||
| Practice Location | |||||||||
| Address1: | 35 DOCK ST | ||||||||
| Address2: | |||||||||
| City: | YONKERS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 107012733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9149651109 | ||||||||
| FaxNumber: | 9149659705 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2009 | ||||||||
| LastUpdateDate: | 09/23/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | R046672 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1285628552 | 01 | NY | AGENCY NPI # | OTHER | 00355940 | 01 | NY | AGENCY MEDICAID ID | OTHER | WVE061 | 01 | NY | AGENCY MEDICARE ID | OTHER |