1669481362 NPI number — DIANNE JESIKIEWICZ LCSWR

Table of content: DIANNE JESIKIEWICZ LCSWR (NPI 1669481362)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669481362 NPI number — DIANNE JESIKIEWICZ LCSWR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JESIKIEWICZ
Provider First Name:
DIANNE
Provider Middle Name:
Provider Name Prefix Text:
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:
1669481362
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/10/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
227 THORN AVE
Provider Second Line Business Mailing Address:
PO BOX 631
Provider Business Mailing Address City Name:
ORCHARD PARK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14127-2600
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-662-2040
Provider Business Mailing Address Fax Number:
716-662-0019

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2309 EGGERT RD
Provider Second Line Business Practice Location Address:
SUITE 9
Provider Business Practice Location Address City Name:
TONAWANDA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14150-9200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-831-1856
Provider Business Practice Location Address Fax Number:
716-831-0263
Provider Enumeration Date:
08/05/2006

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:  R034781 , 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: 000524126002 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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