Provider Demographics
NPI:1073374781
Name:MODEL OF RESILIENCE PSYCHOTHERAPY LCSW PLLC
Entity Type:Organization
Organization Name:MODEL OF RESILIENCE PSYCHOTHERAPY LCSW PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:EBONESHA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:585-794-0641
Mailing Address - Street 1:53 FALLESON RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14612-5751
Mailing Address - Country:US
Mailing Address - Phone:585-794-0641
Mailing Address - Fax:
Practice Address - Street 1:2024 W HENRIETTA RD STE 2A
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14623-1357
Practice Address - Country:US
Practice Address - Phone:585-734-9381
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-19
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty