Healthcare Provider Details

I. General information

NPI: 1992795843
Provider Name (Legal Business Name): RACHELE A. POLLACK LCSW-R, CASAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 10/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 N TIOGA ST
ITHACA NY
14850-4205
US

IV. Provider business mailing address

304 SARANAC WAY
ITHACA NY
14850-9489
US

V. Phone/Fax

Practice location:
  • Phone: 607-269-0187
  • Fax:
Mailing address:
  • Phone: 607-277-7363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number2511
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR028831
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: