Healthcare Provider Details

I. General information

NPI: 1003213802
Provider Name (Legal Business Name): RICHARD VACTOR I LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/24/2014
Last Update Date: 11/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

177 EAST 122ND STREET
NEW YORK NY
10035
US

IV. Provider business mailing address

56 MADELEINE AVE
NEW ROCHELLE NY
10801-3615
US

V. Phone/Fax

Practice location:
  • Phone: 212-360-7116
  • Fax: 212-360-7183
Mailing address:
  • Phone: 914-349-3723
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number079647
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: