1013907872 NPI number — MRS. KELLEY M THORP WOLCOTT LCSWR

Table of content: MRS. KELLEY M THORP WOLCOTT LCSWR (NPI 1013907872)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013907872 NPI number — MRS. KELLEY M THORP WOLCOTT LCSWR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THORP WOLCOTT
Provider First Name:
KELLEY
Provider Middle Name:
M
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCSWR
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:
1013907872
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1231 GREEN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
UTICA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13502-3946
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-797-0472
Provider Business Mailing Address Fax Number:
315-797-6066

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1231 GREEN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
UTICA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13502-3946
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-797-0472
Provider Business Practice Location Address Fax Number:
315-797-6066
Provider Enumeration Date:
10/24/2005

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:  R058963-1 , 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: 02456733 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 209825 . This is a "EXCELLUS BCBS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 7568623 . This is a "AETNA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 476596 . This is a "VALUE OPTIONS PIN" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 361914 . This is a "MVP PIN#" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".