=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811002405
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOANNA PAULA BOGDAN-FYLES LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/21/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 E GENESEE ST SUITE 228
-----------------------------------------------------
City | SYRACUSE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13202-3130
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-234-0213
-----------------------------------------------------
Fax | 315-234-0214
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 600 E GENESEE ST SUITE 228
-----------------------------------------------------
City | SYRACUSE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13202-3130
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-234-0213
-----------------------------------------------------
Fax | 315-234-0214
-----------------------------------------------------
=====================================================
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 | R034387-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------