=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922286079
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JO L. VANDERKLOOT LCSW, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2008
-----------------------------------------------------
Last Update Date | 01/31/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 83 ONDERDONK RD
-----------------------------------------------------
City | WARWICK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10990-2909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-986-3560
-----------------------------------------------------
Fax | 845-986-0255
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 83 ONDERDONK RD
-----------------------------------------------------
City | WARWICK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10990-2909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-986-3560
-----------------------------------------------------
Fax | 845-986-0255
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MS. JO L VANDERKLOOT
-----------------------------------------------------
Credential | MSW
-----------------------------------------------------
Telephone | 845-986-3560
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | R-029237-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------