Provider Demographics
NPI:1558338608
Name:CONKLIN, CAROL A (LCSW-R)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:A
Last Name:CONKLIN
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 ASHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14222-1309
Mailing Address - Country:US
Mailing Address - Phone:716-883-7713
Mailing Address - Fax:716-883-6718
Practice Address - Street 1:610 ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14222-1309
Practice Address - Country:US
Practice Address - Phone:716-883-7713
Practice Address - Fax:716-883-6718
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-07
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR055959-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00020965201OtherUNIVERA PROVIDER #
NY000526017001OtherBC BS BUFFALO
NY161587546OtherTRICARE PROVIDER #
NY000526017002OtherBC BS NATIONAL
NYQ17648Medicare UPIN
NYIA0522Medicare ID - Type Unspecified