Provider Demographics
NPI:1780653931
Name:WOLK, GARY SCOTT (LCSW-R, CASAC, CGP)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:SCOTT
Last Name:WOLK
Suffix:
Gender:M
Credentials:LCSW-R, CASAC, CGP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:NY
Mailing Address - Zip Code:14414-1006
Mailing Address - Country:US
Mailing Address - Phone:585-226-3842
Mailing Address - Fax:
Practice Address - Street 1:16 N GOODMAN ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14607-1554
Practice Address - Country:US
Practice Address - Phone:585-546-6560
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5666101YA0400X
NYR0580241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02561291Medicaid
NY114045FKOtherPREFERRED CARE/MVP HEALTH
NY7758505OtherAETNA PPO/POS (PIN)
NYP14975Medicare UPIN
NY114045FKOtherPREFERRED CARE/MVP HEALTH