Healthcare Provider Details

I. General information

NPI: 1861047292
Provider Name (Legal Business Name): SANKOFA FAMILY COUNSELING SERVICES, LCSW P.L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2019
Last Update Date: 08/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 PORTLAND AVE STE 54
ROCHESTER NY
14621-3014
US

IV. Provider business mailing address

1400 PORTLAND AVE STE 54
ROCHESTER NY
14621-3014
US

V. Phone/Fax

Practice location:
  • Phone: 585-491-6646
  • Fax: 585-363-5822
Mailing address:
  • Phone: 585-491-6646
  • Fax: 585-363-5822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: KHADIJAH ELLA TILLMAN
Title or Position: CLINICAL SOCIAL WORKER
Credential: LCSW
Phone: 585-713-2071