=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740678648
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VIOLETA A TESLEV-KLETT LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/30/2014
-----------------------------------------------------
Last Update Date | 09/01/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 54 NORTH AVE
-----------------------------------------------------
City | OWEGO
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13827-1325
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-307-1001
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3201 MONTROSE TPKE
-----------------------------------------------------
City | OWEGO
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13827-6925
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-283-7314
-----------------------------------------------------
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 | 087699
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------