Provider Demographics
NPI:1760443113
Name:KOLESNIKOV, DANIEL (LCSW R)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:
Last Name:KOLESNIKOV
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 1:4497 RYNEX CORNERS ROAD
Mailing Address - Street 2:
Mailing Address - City:PATTERSONVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12137
Mailing Address - Country:US
Mailing Address - Phone:518-887-2636
Mailing Address - Fax:
Practice Address - Street 1:57 E FULTON STREET
Practice Address - Street 2:
Practice Address - City:GLOVERSVILLE
Practice Address - State:NY
Practice Address - Zip Code:12078
Practice Address - Country:US
Practice Address - Phone:518-773-3531
Practice Address - Fax:518-773-9103
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR03488211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CC4873Medicare ID - Type Unspecified
P28178Medicare UPIN