Provider Demographics
NPI:1982070520
Name:EASTSIDECOUNSELINGSERVICESSYRACUSE
Entity type:Organization
Organization Name:EASTSIDECOUNSELINGSERVICESSYRACUSE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:MARGARET
Authorized Official - Middle Name:WEST
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-R
Authorized Official - Phone:215-606-8654
Mailing Address - Street 1:216 PELHAM RD
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13214-1621
Mailing Address - Country:US
Mailing Address - Phone:215-606-8654
Mailing Address - Fax:
Practice Address - Street 1:216 PELHAM RD
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13214-1621
Practice Address - Country:US
Practice Address - Phone:215-606-8654
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-18
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR018157-11041C0700X
NY077677-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1538446703OtherPRIVATE INSURANCE
NY1235220401OtherPRIVATE INSURANCE