=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902361744
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOSH SWILLER LMSW, BCT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2019
-----------------------------------------------------
Last Update Date | 02/06/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 222 S ALBANY ST
-----------------------------------------------------
City | ITHACA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14850-5471
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-957-1140
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 222 S ALBANY ST
-----------------------------------------------------
City | ITHACA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14850-5471
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | 088590
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------