Healthcare Provider Details

I. General information

NPI: 1053303099
Provider Name (Legal Business Name): BARTLEY J ETTORI LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 NORTH RD
POUGHKEEPSIE NY
12601-1328
US

IV. Provider business mailing address

29 N HAMILTON ST
POUGHKEEPSIE NY
12601-2541
US

V. Phone/Fax

Practice location:
  • Phone: 845-486-2703
  • Fax: 845-486-2865
Mailing address:
  • Phone: 845-452-1110
  • Fax: 845-452-1119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP015203-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: