Healthcare Provider Details

I. General information

NPI: 1629370069
Provider Name (Legal Business Name): JOSEPH TIMOTHY SHANLY LCSW-R
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2010
Last Update Date: 11/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32735 COUNTY ROUTE 29 STE A
PHILADELPHIA NY
13673-4210
US

IV. Provider business mailing address

913 MYRTLE AVE
WATERTOWN NY
13601-4601
US

V. Phone/Fax

Practice location:
  • Phone: 315-642-3142
  • Fax: 315-642-3249
Mailing address:
  • Phone: 315-783-9114
  • Fax: 315-642-3249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number064470
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: