Healthcare Provider Details

I. General information

NPI: 1134232705
Provider Name (Legal Business Name): COLLEEN ANNE VERNOLD LCSW-R
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7900 BEECHES TURIN ROAD, BLDG. 3, STE. 4, BEECHES PROFESSIONAL CAMPUS
ROME NY
13440
US

IV. Provider business mailing address

7900 TURIN ROAD , BLDG. 3, STE. 4 BEECHES PROFESSIONAL CAMPUS
ROME NY
13440
US

V. Phone/Fax

Practice location:
  • Phone: 315-334-4555
  • Fax: 315-334-4554
Mailing address:
  • Phone: 315-334-4555
  • Fax: 315-334-4554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberR052546
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: