Healthcare Provider Details

I. General information

NPI: 1609818335
Provider Name (Legal Business Name): TY A LITTLE LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 07/14/2021
Certification Date: 07/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1132 JOHN LOCKWOOD RD
WALTON NY
13856-2127
US

IV. Provider business mailing address

1132 JOHN LOCKWOOD RD
WALTON NY
13856-2127
US

V. Phone/Fax

Practice location:
  • Phone: 607-643-8143
  • Fax:
Mailing address:
  • Phone: 607-643-8143
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number072582-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: