Provider Demographics
NPI:1316397862
Name:VICARI, SALLY A (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:SALLY
Middle Name:A
Last Name:VICARI
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MISS
Other - First Name:SALLY
Other - Middle Name:A
Other - Last Name:PASTOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:333 DEXTER TER
Mailing Address - Street 2:
Mailing Address - City:TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14150-4747
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:333 DEXTER TER
Practice Address - Street 2:
Practice Address - City:TONAWANDA
Practice Address - State:NY
Practice Address - Zip Code:14150-4747
Practice Address - Country:US
Practice Address - Phone:716-462-4355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-15
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY85817101YM0800X
NY085817101YM0800X
NY08731711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01465154Medicaid