Healthcare Provider Details

I. General information

NPI: 1093130841
Provider Name (Legal Business Name): ELIZABETH JORDAN RADLEY LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2014
Last Update Date: 10/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 ALEXANDER ST
ROCHESTER NY
14607-4000
US

IV. Provider business mailing address

224 ALEXANDER ST
ROCHESTER NY
14607-4000
US

V. Phone/Fax

Practice location:
  • Phone: 585-922-7770
  • Fax: 585-922-7246
Mailing address:
  • Phone: 585-922-7770
  • Fax: 585-922-7246

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number091004
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: