Healthcare Provider Details

I. General information

NPI: 1396136644
Provider Name (Legal Business Name): REBECCA JANE NIDORF LCSW-R
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2015
Last Update Date: 09/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 MORNING STAR DR
NEW PALTZ NY
12561-2932
US

IV. Provider business mailing address

11 MORNING STAR DR
NEW PALTZ NY
12561-2932
US

V. Phone/Fax

Practice location:
  • Phone: 845-505-1863
  • Fax:
Mailing address:
  • Phone: 845-505-1863
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number071078-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: