=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679949317
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BETH A WALDO WINDSOR COUNSELING EAST
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/17/2015
-----------------------------------------------------
Last Update Date | 08/17/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 555 BLOOMING GROVE TPKE SUITE 101
-----------------------------------------------------
City | NEW WINDSOR
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12553-7843
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-565-6888
-----------------------------------------------------
Fax | 845-565-0142
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 555 BLOOMING GROVE TPKE SUITE 101
-----------------------------------------------------
City | NEW WINDSOR
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12553-7843
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-565-6888
-----------------------------------------------------
Fax | 845-565-0142
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ DIRECTOR
-----------------------------------------------------
Name | MRS. BETH A WALDO
-----------------------------------------------------
Credential | CSW
-----------------------------------------------------
Telephone | 845-565-6888
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 081493
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------