Healthcare Provider Details

I. General information

NPI: 1699222422
Provider Name (Legal Business Name): TIMOTHY SMALLCOMB LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2016
Last Update Date: 05/06/2022
Certification Date: 05/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

490 E RIDGE RD
ROCHESTER NY
14621-1229
US

IV. Provider business mailing address

490 E RIDGE RD
ROCHESTER NY
14621-1229
US

V. Phone/Fax

Practice location:
  • Phone: 585-922-2500
  • Fax: 585-922-2684
Mailing address:
  • Phone: 585-922-2500
  • Fax: 585-922-2684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number091983
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number091983
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: