Provider Demographics
NPI:1568532554
Name:PRENTICE, JANETTE GRANHOLM (LCSW)
Entity Type:Individual
Prefix:
First Name:JANETTE
Middle Name:GRANHOLM
Last Name:PRENTICE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ENDICOTT
Mailing Address - State:NY
Mailing Address - Zip Code:13760
Mailing Address - Country:US
Mailing Address - Phone:607-754-2660
Mailing Address - Fax:607-754-0769
Practice Address - Street 1:202 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ENDICOTT
Practice Address - State:NY
Practice Address - Zip Code:13760
Practice Address - Country:US
Practice Address - Phone:607-754-2660
Practice Address - Fax:607-754-0769
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0718131104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY167241OtherBCBS
NY61699OtherMVP
NY61699OtherMVP
NYDD5437Medicare ID - Type Unspecified