=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801334024
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANNE E. KEARNEY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/08/2017
-----------------------------------------------------
Last Update Date | 02/08/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 229 ROBINEAU RD
-----------------------------------------------------
City | SYRACUSE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13207-1643
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-345-2403
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 528 OAK ST
-----------------------------------------------------
City | SYRACUSE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13203-1643
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-345-2403
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICIAN
-----------------------------------------------------
Name | MS. ANNE E. KEARNEY
-----------------------------------------------------
Credential | MSW
-----------------------------------------------------
Telephone | 315-345-2403
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | R031913-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------