Provider Demographics
NPI:1962587857
Name:BRUCE, LENORE MENNIN (LCSW)
Entity type:Individual
Prefix:
First Name:LENORE
Middle Name:MENNIN
Last Name:BRUCE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3623 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:STONE RIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:12484-5613
Mailing Address - Country:US
Mailing Address - Phone:845-687-7597
Mailing Address - Fax:
Practice Address - Street 1:3623 MAIN ST
Practice Address - Street 2:
Practice Address - City:STONE RIDGE
Practice Address - State:NY
Practice Address - Zip Code:12484-5613
Practice Address - Country:US
Practice Address - Phone:845-687-0687
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYLCSWR0190441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN4148Medicare ID - Type Unspecified