Provider Demographics
NPI:1659723831
Name:R RAYMOND TARTAKOFF LCSW PC
Entity Type:Organization
Organization Name:R RAYMOND TARTAKOFF LCSW PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/GM
Authorized Official - Prefix:MR
Authorized Official - First Name:R
Authorized Official - Middle Name:RAYMOND
Authorized Official - Last Name:TARTAKOFF
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:845-647-2112
Mailing Address - Street 1:216 CONTINENTAL RD
Mailing Address - Street 2:
Mailing Address - City:NAPANOCH
Mailing Address - State:NY
Mailing Address - Zip Code:12458-2602
Mailing Address - Country:US
Mailing Address - Phone:845-647-2112
Mailing Address - Fax:
Practice Address - Street 1:216 CONTINENTAL RD
Practice Address - Street 2:
Practice Address - City:NAPANOCH
Practice Address - State:NY
Practice Address - Zip Code:12458-2602
Practice Address - Country:US
Practice Address - Phone:845-647-2112
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-12
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053380101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
7491605OtherVALUE OPTIONS
NY01727242Medicaid