Healthcare Provider Details

I. General information

NPI: 1215346200
Provider Name (Legal Business Name): DARA LEE WURZBURG LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2014
Last Update Date: 11/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 WILLIAM ST
GOUVERNEUR NY
13642-1405
US

IV. Provider business mailing address

28 WILLIAM ST
GOUVERNEUR NY
13642-1405
US

V. Phone/Fax

Practice location:
  • Phone: 315-287-2811
  • Fax: 315-287-4743
Mailing address:
  • Phone: 315-287-2811
  • Fax: 315-287-4743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number090417-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: