Healthcare Provider Details

I. General information

NPI: 1619073376
Provider Name (Legal Business Name): DEWITT COUNSELING SERVICES LCSW PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 03/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5800 HERITAGE LANDING DR SUITE E
EAST SYRACUSE NY
13057-9378
US

IV. Provider business mailing address

5800 HERITAGE LANDING DR SUITE E
EAST SYRACUSE NY
13057-9378
US

V. Phone/Fax

Practice location:
  • Phone: 315-472-7885
  • Fax: 315-472-2513
Mailing address:
  • Phone: 315-472-7885
  • Fax: 315-472-2513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DONALD T GARDINER
Title or Position: PRESIDENT
Credential: LCSWR
Phone: 315-472-7885