MEDICARE: WINGSPAN COUNSELING LCSW PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker

General Provider Information

NPI Number	:	1013691344
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WINGSPAN COUNSELING LCSW PLLC

Provider Business Mailing Address
First Line	:	95 ALLENS CREEK RD STE 9
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14618-3252
Country	:	US
Telephone Number	:	585-568-7864
Fax Number	:	855-523-1669

Provider Business Practice Location Address
First Line	:	95 ALLENS CREEK RD STE 9
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14618-3252
Country	:	US
Telephone Number	:	585-568-7864
Fax Number	:	855-523-1669

Authorized Official
Title or Position	:	ORIGINAL MEMBER/MANAGER/ LCSW
Name	:	MS. SHARON DAWN MATTSSON
Credential	:	LCSW
Telephone Number	:	585-568-7864

Provider Enumeration Date	:	06/15/2023
Last Update Date	:	06/15/2023

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