Healthcare Provider Details

I. General information

NPI: 1487719746
Provider Name (Legal Business Name): KIM M TEDALDI LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 03/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 LOTHROP LN
TIVOLI NY
12583-5414
US

IV. Provider business mailing address

10 LOTHROP LN
TIVOLI NY
12583-5414
US

V. Phone/Fax

Practice location:
  • Phone: 845-757-2707
  • Fax:
Mailing address:
  • Phone: 845-757-2707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number079725
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: