=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972838506
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SANDRA POLLARO LCSW-R
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/15/2009
-----------------------------------------------------
Last Update Date | 01/23/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1153 BURGOYNE AVENUE HUDSON FALLS CENTRAL SCHOOL DISTRICT
-----------------------------------------------------
City | FORT EDWARD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12828
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-747-2121
-----------------------------------------------------
Fax | 518-747-0951
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 144 FARR LN
-----------------------------------------------------
City | QUEENSBURY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12804-1989
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-793-0792
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 076330
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------