=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770672065
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY ELLEN KRANOCK
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5500 MAIN ST SUITE 207
-----------------------------------------------------
City | WILLIAMSVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14221-6755
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-505-5634
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 215 MARTIN RD
-----------------------------------------------------
City | AKRON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14001-9101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-542-6428
-----------------------------------------------------
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 | R049293-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------