=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093047045
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALCHEMY OF AGING, LESLIE K MALIN, LCSW PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/02/2010
-----------------------------------------------------
Last Update Date | 02/02/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17 VALLEY ST
-----------------------------------------------------
City | SAUGERTIES
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12477-1829
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-706-3114
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17 VALLEY STREET
-----------------------------------------------------
City | SAUGERTIES
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12477-1829
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-706-3114
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MS. LESLIE KAREN MALIN
-----------------------------------------------------
Credential | MSW
-----------------------------------------------------
Telephone | 845-706-3114
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 021282-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------