Healthcare Provider Details

I. General information

NPI: 1659723831
Provider Name (Legal Business Name): R RAYMOND TARTAKOFF LCSW PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2016
Last Update Date: 07/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 CONTINENTAL RD
NAPANOCH NY
12458-2602
US

IV. Provider business mailing address

216 CONTINENTAL RD
NAPANOCH NY
12458-2602
US

V. Phone/Fax

Practice location:
  • Phone: 845-647-2112
  • Fax:
Mailing address:
  • Phone: 845-647-2112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number053380
License Number StateNY

VIII. Authorized Official

Name: MR. R RAYMOND TARTAKOFF
Title or Position: OWNER/GM
Credential: LCSW
Phone: 845-647-2112