Provider Demographics
NPI:1326101239
Name:WEIDERMAN, REBECCA A (MSW LMSW)
Entity Type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:A
Last Name:WEIDERMAN
Suffix:
Gender:F
Credentials:MSW LMSW
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:A
Other - Last Name:VANWIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW LCSW
Mailing Address - Street 1:102 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:12095
Mailing Address - Country:US
Mailing Address - Phone:518-762-5256
Mailing Address - Fax:
Practice Address - Street 1:FULTON COUNTY ADDICTION SERVICES
Practice Address - Street 2:73 NORTH MAIN STREET 3RD FLOOR
Practice Address - City:GLOVERSVILLE
Practice Address - State:NY
Practice Address - Zip Code:12078
Practice Address - Country:US
Practice Address - Phone:518-773-3532
Practice Address - Fax:518-773-4003
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0520681104100000X
NY077758-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker