Healthcare Provider Details

I. General information

NPI: 1679858096
Provider Name (Legal Business Name): JEAN M WHEELER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2011
Last Update Date: 10/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 MAPLE HEIGHTS
BATH NY
14810
US

IV. Provider business mailing address

216 MAPLE HEIGHTS
BATH NY
14810
US

V. Phone/Fax

Practice location:
  • Phone: 607-776-4123
  • Fax: 607-776-4124
Mailing address:
  • Phone: 607-776-4123
  • Fax: 607-776-4124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number078518-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: