Provider Demographics
NPI:1962570820
Name:ENIGK, TANYA M (LCSW-R)
Entity type:Individual
Prefix:MRS
First Name:TANYA
Middle Name:M
Last Name:ENIGK
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:MISS
Other - First Name:TANYA
Other - Middle Name:M
Other - Last Name:GILLEECE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW-R
Mailing Address - Street 1:332 ROBERTSON RD
Mailing Address - Street 2:
Mailing Address - City:SHERRILL
Mailing Address - State:NY
Mailing Address - Zip Code:13461-1367
Mailing Address - Country:US
Mailing Address - Phone:315-762-2144
Mailing Address - Fax:315-363-9286
Practice Address - Street 1:5457 EAST SENECA STREET
Practice Address - Street 2:
Practice Address - City:VERNON
Practice Address - State:NY
Practice Address - Zip Code:13476
Practice Address - Country:US
Practice Address - Phone:315-762-2144
Practice Address - Fax:315-363-9286
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY07109211041C0700X
NY73071092104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0720007192Medicaid
NY0720007192Medicaid