Healthcare Provider Details

I. General information

NPI: 1215076625
Provider Name (Legal Business Name): VALERIE-LYNN ANAWALD MUTKA LCSW-R
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 04/13/2020
Certification Date: 04/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 57
CORFU NY
14036-0057
US

IV. Provider business mailing address

PO BOX 57
CORFU NY
14036-0057
US

V. Phone/Fax

Practice location:
  • Phone: 585-813-4075
  • Fax:
Mailing address:
  • Phone: 585-813-4075
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR077841-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: