=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780790618
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | COLLEEN L WOLPERT LCSWR
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2006
-----------------------------------------------------
Last Update Date | 08/06/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 232 MAIN ST
-----------------------------------------------------
City | BINGHAMTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13905-2610
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-729-9166
-----------------------------------------------------
Fax | 607-729-2062
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 232 MAIN ST
-----------------------------------------------------
City | BINGHAMTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13905-2610
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-729-9166
-----------------------------------------------------
Fax | 607-729-2062
-----------------------------------------------------
=====================================================
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 | R050733-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------