=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326574534
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WENDELL COVELL LMSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2017
-----------------------------------------------------
Last Update Date | 05/08/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 50 PRESIDENTIAL PLAZA JEFFERSON TOWER SUITE LL05
-----------------------------------------------------
City | SYRACUSE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-877-4461
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 209 STILLWELL CIR
-----------------------------------------------------
City | EAST SYRACUSE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13057-1621
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-479-1359
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 097498
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------