Healthcare Provider Details

I. General information

NPI: 1003452939
Provider Name (Legal Business Name): ANDREW JAMES FIDURKO LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2019
Last Update Date: 10/16/2023
Certification Date: 10/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 E CAYUGA ST
OSWEGO NY
13126-1241
US

IV. Provider business mailing address

110 W 6TH ST
OSWEGO NY
13126-2507
US

V. Phone/Fax

Practice location:
  • Phone: 315-326-4100
  • Fax:
Mailing address:
  • Phone: 315-349-5511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number081157
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number095297
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: