=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316648710
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WESTERN NEW YORK LICENSED CLINICAL SOCIAL WORK SERVICES, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2023
-----------------------------------------------------
Last Update Date | 03/13/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 N. FOREST RD. STE #S256
-----------------------------------------------------
City | WILLIAMSVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14221-5056
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-628-5296
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 223 COTTONWOOD DRIVE
-----------------------------------------------------
City | WILLIAMSVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14221-1608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-628-5296
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/FOUNDER
-----------------------------------------------------
Name | SHIRLEY B. MAZOUREK
-----------------------------------------------------
Credential | LCSW-R
-----------------------------------------------------
Telephone | 716-628-5296
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------