Provider Demographics
NPI:1326511262
Name:SOLOMON, VINCE
Entity Type:Individual
Prefix:
First Name:VINCE
Middle Name:
Last Name:SOLOMON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:432 STONE HOUSE RD
Mailing Address - Street 2:
Mailing Address - City:FLY CREEK
Mailing Address - State:NY
Mailing Address - Zip Code:13337-2502
Mailing Address - Country:US
Mailing Address - Phone:267-407-1673
Mailing Address - Fax:
Practice Address - Street 1:432 STONE HOUSE RD
Practice Address - Street 2:
Practice Address - City:FLY CREEK
Practice Address - State:NY
Practice Address - Zip Code:13337-2502
Practice Address - Country:US
Practice Address - Phone:267-407-1673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-03
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
NY105795104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst