=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134711211
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELIZABETH PODGORNY LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2021
-----------------------------------------------------
Last Update Date | 09/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 DELSAN CT
-----------------------------------------------------
City | BUFFALO
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14216-1223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-444-6385
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 DELSAN CT
-----------------------------------------------------
City | BUFFALO
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14216-1223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-444-6385
-----------------------------------------------------
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 | 097726
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------