=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265514889
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATHRYN RESOVSKY BAINE LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/20/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 435 MAIN ST
-----------------------------------------------------
City | JOHNSON CITY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13790
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-729-8101
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 260 PIERCE HILL RD
-----------------------------------------------------
City | VESTAL
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13850-5306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-748-0122
-----------------------------------------------------
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 | 075449
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------