=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942579800
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRUCE R MARDINEY LCSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/22/2011
-----------------------------------------------------
Last Update Date | 12/22/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 175 ROUTE 32 NORTH
-----------------------------------------------------
City | NEW PALTZ
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12561
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-255-1400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 175 MOUNTAIN RD
-----------------------------------------------------
City | ROSENDALE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12472-9652
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-658-3467
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041S0200X
-----------------------------------------------------
Taxonomy Name | School Social Worker
-----------------------------------------------------
License Number | 069967-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------