Healthcare Provider Details

I. General information

NPI: 1295088979
Provider Name (Legal Business Name): LAURA JEANNE SYVERTSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2012
Last Update Date: 10/03/2025
Certification Date: 10/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 N TIOGA
ITHACA NY
14850
US

IV. Provider business mailing address

409 ELM ST
ITHACA NY
14850
US

V. Phone/Fax

Practice location:
  • Phone: 607-220-7319
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number097203-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: