Healthcare Provider Details

I. General information

NPI: 1558338608
Provider Name (Legal Business Name): CAROL A CONKLIN LCSW-R
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2006
Last Update Date: 10/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 ASHLAND AVE
BUFFALO NY
14222-1309
US

IV. Provider business mailing address

610 ASHLAND AVE
BUFFALO NY
14222-1309
US

V. Phone/Fax

Practice location:
  • Phone: 716-883-7713
  • Fax: 716-883-6718
Mailing address:
  • Phone: 716-883-7713
  • Fax: 716-883-6718

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR055959-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: