Provider Demographics
NPI:1790972107
Name:JOANNA BOGDAN-FYLES, LCSW, PLLC
Entity Type:Organization
Organization Name:JOANNA BOGDAN-FYLES, LCSW, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JOANNA
Authorized Official - Middle Name:PAULA
Authorized Official - Last Name:BOGDAN-FYLES
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:315-234-0213
Mailing Address - Street 1:600 E GENESEE ST
Mailing Address - Street 2:SUITE 228
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13202-3130
Mailing Address - Country:US
Mailing Address - Phone:315-234-0213
Mailing Address - Fax:315-234-0214
Practice Address - Street 1:600 E GENESEE ST
Practice Address - Street 2:SUITE 228
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13202-3130
Practice Address - Country:US
Practice Address - Phone:315-234-0213
Practice Address - Fax:315-234-0214
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-29
Last Update Date:2007-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR034387-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
S02778Medicare UPIN