Healthcare Provider Details

I. General information

NPI: 1326426313
Provider Name (Legal Business Name): EILEEN VICKERY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2015
Last Update Date: 05/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

396 BROADWAY
MONTICELLO NY
12701-1157
US

IV. Provider business mailing address

PO BOX 25 30 SPRUCE STREET WEST
WURTSBORO NY
12790-0025
US

V. Phone/Fax

Practice location:
  • Phone: 845-794-8080
  • Fax:
Mailing address:
  • Phone: 845-800-7465
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number29481
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: