Provider Demographics
NPI:1689981417
Name:VANDER KOOY, EDO GEORGE (LCSW-R)
Entity Type:Individual
Prefix:MR
First Name:EDO
Middle Name:GEORGE
Last Name:VANDER KOOY
Suffix:
Gender:M
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 1:79 UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14214-1224
Mailing Address - Country:US
Mailing Address - Phone:716-838-1914
Mailing Address - Fax:716-282-2184
Practice Address - Street 1:79 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14214-1224
Practice Address - Country:US
Practice Address - Phone:716-838-1914
Practice Address - Fax:716-282-2184
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-31
Last Update Date:2013-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0200681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYR020068OtherNEW YORK STATE EDUCATION DEPARTMENT - LICENSED CLINICAL SOCIAL WORKER