Provider Demographics
NPI:1154903540
Name:INTENTIONAL IMPACT LMSW PLLC
Entity type:Organization
Organization Name:INTENTIONAL IMPACT LMSW PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CASWELL
Authorized Official - Middle Name:VINCENT
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:585-290-2224
Mailing Address - Street 1:547 CEDARWOOD TER
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14609-7154
Mailing Address - Country:US
Mailing Address - Phone:585-290-2224
Mailing Address - Fax:
Practice Address - Street 1:1350 BUFFALO RD STE 18
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14624-1856
Practice Address - Country:US
Practice Address - Phone:585-290-2224
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-25
Last Update Date:2021-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)