Healthcare Provider Details

I. General information

NPI: 1841471869
Provider Name (Legal Business Name): POLA BEAGLE LCSW-R
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2007
Last Update Date: 11/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 SCHOOL ST
SHERBURNE NY
13460-9505
US

IV. Provider business mailing address

PO BOX 725
COOPERSTOWN NY
13326-0725
US

V. Phone/Fax

Practice location:
  • Phone: 607-674-8416
  • Fax:
Mailing address:
  • Phone: 607-674-8416
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number074530
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: