=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134265705
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LINDA NELSON LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/30/2007
-----------------------------------------------------
Last Update Date | 11/13/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 116 MAIN ST
-----------------------------------------------------
City | PENN YAN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14527-1806
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-377-2354
-----------------------------------------------------
Fax | 607-292-6810
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14173 KEUKA VILLAGE RD
-----------------------------------------------------
City | DUNDEE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14837-9621
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-377-2354
-----------------------------------------------------
Fax | 607-292-6810
-----------------------------------------------------
=====================================================
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 | 078310
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------