Provider Demographics
NPI:1659420826
Name:VEDDER, PHYLLIS (LCSW)
Entity Type:Individual
Prefix:MS
First Name:PHYLLIS
Middle Name:
Last Name:VEDDER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:PHYLLIS
Other - Middle Name:
Other - Last Name:FALCIGLIA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:89 DALY ROAD
Mailing Address - Street 2:
Mailing Address - City:EAST NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11731-6307
Mailing Address - Country:US
Mailing Address - Phone:631-462-5987
Mailing Address - Fax:631-462-5987
Practice Address - Street 1:89 DALY ROAD
Practice Address - Street 2:
Practice Address - City:EAST NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11731-6307
Practice Address - Country:US
Practice Address - Phone:631-462-5987
Practice Address - Fax:631-462-5987
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0207051104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN8876180Medicare ID - Type Unspecified