Healthcare Provider Details

I. General information

NPI: 1558700740
Provider Name (Legal Business Name): HEATHER L. HULSE LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2013
Last Update Date: 06/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

465 N MAIN ST JOHN D. KELLY BEHAVIORAL HEALTH
PENN YAN NY
14527-1069
US

IV. Provider business mailing address

421 N MAIN ST
PENN YAN NY
14527-1012
US

V. Phone/Fax

Practice location:
  • Phone: 315-531-2400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number059646-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: