=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992119283
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JILL VAN PELT LCSW PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/16/2014
-----------------------------------------------------
Last Update Date | 06/16/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4513 OLD VESTAL RD
-----------------------------------------------------
City | VESTAL
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13850-3571
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-729-7001
-----------------------------------------------------
Fax | 607-729-6434
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 29 DOWNS AVE
-----------------------------------------------------
City | BINGHAMTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13905-1822
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-595-9120
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL SOCIAL WORKER
-----------------------------------------------------
Name | MRS. JILL A MESKUNAS-VAN PELT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 607-595-9120
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | R069978
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------