=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750808515
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA S SEIDEL
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2017
-----------------------------------------------------
Last Update Date | 08/23/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 547 SAW MILL RIVER RD STE 1A
-----------------------------------------------------
City | ARDSLEY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10502-2154
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-892-9692
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15 S ECKAR ST
-----------------------------------------------------
City | IRVINGTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10533-1606
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-892-9692
-----------------------------------------------------
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 | 076142-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------