=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598913816
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOANNA MARIE-KELTOS TOMPKINS LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2008
-----------------------------------------------------
Last Update Date | 01/13/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 116 CLAYTON AVE STE A
-----------------------------------------------------
City | VESTAL
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13850-2430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-754-1101
-----------------------------------------------------
Fax | 607-754-1107
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 116 CLAYTON AVE STE A
-----------------------------------------------------
City | VESTAL
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13850-2430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-754-1101
-----------------------------------------------------
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 | 080521
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------