Provider Demographics
NPI:1821757055
Name:THEOPHANIS, LYNNE (LMSW)
Entity Type:Individual
Prefix:
First Name:LYNNE
Middle Name:
Last Name:THEOPHANIS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:VESTAL
Mailing Address - State:NY
Mailing Address - Zip Code:13850-1513
Mailing Address - Country:US
Mailing Address - Phone:607-321-9179
Mailing Address - Fax:
Practice Address - Street 1:38 RIVERSIDE DR STE 3
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13905-4596
Practice Address - Country:US
Practice Address - Phone:607-215-1705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-15
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY091712104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY091712OtherLICENSED MASTER SOCIAL WORKER