Provider Demographics
NPI:1982171559
Name:GANDOLFO, JILL (LMSW)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:GANDOLFO
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 DELAWARE CT
Mailing Address - Street 2:
Mailing Address - City:REXFORD
Mailing Address - State:NY
Mailing Address - Zip Code:12148-1351
Mailing Address - Country:US
Mailing Address - Phone:518-339-0372
Mailing Address - Fax:
Practice Address - Street 1:30 PASHLEY RD
Practice Address - Street 2:
Practice Address - City:GLENVILLE
Practice Address - State:NY
Practice Address - Zip Code:12302-5438
Practice Address - Country:US
Practice Address - Phone:518-399-9141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-31
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY082705104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker