MEDICARE: MS. CAROL A CONKLIN LCSW-R

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	R055959-1	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00020965201	OTHER	NY	UNIVERA PROVIDER #
2	000526017001	OTHER	NY	BC BS BUFFALO
3	161587546	OTHER	NY	TRICARE PROVIDER #
4	000526017002	OTHER	NY	BC BS NATIONAL

General Provider Information

NPI Number	:	1558338608
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CAROL A CONKLIN LCSW-R

Provider Business Mailing Address
First Line	:	610 ASHLAND AVE
Second Line	:
City	:	BUFFALO
State	:	NY
Zip	:	14222-1309
Country	:	US
Telephone Number	:	716-883-7713
Fax Number	:	716-883-6718

Provider Business Practice Location Address
First Line	:	610 ASHLAND AVE
Second Line	:
City	:	BUFFALO
State	:	NY
Zip	:	14222-1309
Country	:	US
Telephone Number	:	716-883-7713
Fax Number	:	716-883-6718

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/07/2006
Last Update Date	:	10/19/2016

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