Provider Demographics
NPI:1225260292
Name:FENDRICH, WALTER (LCSW)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:
Last Name:FENDRICH
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 RIVER RD
Mailing Address - Street 2:#10E
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10044-1100
Mailing Address - Country:US
Mailing Address - Phone:917-363-5279
Mailing Address - Fax:718-472-5222
Practice Address - Street 1:20 RIVER RD
Practice Address - Street 2:#10E
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10044-1100
Practice Address - Country:US
Practice Address - Phone:917-363-5279
Practice Address - Fax:718-472-5222
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-10
Last Update Date:2009-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR060351-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY368736Medicare UPIN