=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285026419
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALKIRA MARRIAGE AND FAMILY THERAPY PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/25/2015
-----------------------------------------------------
Last Update Date | 05/23/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6700 KIRKVILLE ROAD BUILDING B SUITE 107
-----------------------------------------------------
City | EAST SYRACUSE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13057-9373
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-492-1390
-----------------------------------------------------
Fax | 315-314-7726
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6700 KIRKVILLE ROAD BUILDING B SUITE 107
-----------------------------------------------------
City | EAST SYRACUSE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13057-9373
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-492-1390
-----------------------------------------------------
Fax | 315-314-7726
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JILL WELDUM
-----------------------------------------------------
Credential | LMFT, MA
-----------------------------------------------------
Telephone | 315-492-1390
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 000070
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------