Provider Demographics
NPI:1467895482
Name:TAVENIERE, EILEEN (LMSW)
Entity Type:Individual
Prefix:MS
First Name:EILEEN
Middle Name:
Last Name:TAVENIERE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4788 EDGEWORTH DR
Mailing Address - Street 2:
Mailing Address - City:MANLIUS
Mailing Address - State:NY
Mailing Address - Zip Code:13104-2106
Mailing Address - Country:US
Mailing Address - Phone:315-682-6944
Mailing Address - Fax:
Practice Address - Street 1:200 W DOMINICK ST
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13440-5838
Practice Address - Country:US
Practice Address - Phone:315-339-6536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-09
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY062100-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker