=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003213802
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RICHARD VACTOR I LMSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/24/2014
-----------------------------------------------------
Last Update Date | 11/24/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 177 EAST 122ND STREET
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10035
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-360-7116
-----------------------------------------------------
Fax | 212-360-7183
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 56 MADELEINE AVE
-----------------------------------------------------
City | NEW ROCHELLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10801-3615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-349-3723
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 079647
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------