=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811059603
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MOLLY EILEEN PHELPS LMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/15/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5980 S STREET RD
-----------------------------------------------------
City | AUBURN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13021-5678
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-253-0361
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3096 KINGSBRIDGE LN
-----------------------------------------------------
City | BALDWINSVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13027-1628
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-635-2490
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------