1699831396 NPI number — MS. ILENE GAFFIN LCSW

Table of content: MS. ILENE GAFFIN LCSW (NPI 1699831396)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699831396 NPI number — MS. ILENE GAFFIN LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GAFFIN
Provider First Name:
ILENE
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1699831396
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/26/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
320 LINN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ITHACA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14850-3719
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
607-275-0558
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 E BUFFALO ST
Provider Second Line Business Practice Location Address:
STE 4
Provider Business Practice Location Address City Name:
ITHACA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14850-4266
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
607-275-0558
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  R022620 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 138407 . This is a "VO BMP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 209429 . This is a "EXCELLUS HMO BLUE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 28552230 . This is a "EXCELLUS CNY CSWR" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5059010 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0005363002 . This is a "GHI EMPIRE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000914002001 . This is a "HEALTH NOW" identifier . This identifiers is of the category "OTHER".




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