Provider Demographics
NPI:1124711536
Name:KLENCHIK, JOHN ROBERT (LMSW)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:ROBERT
Last Name:KLENCHIK
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 KENTUCKY AVE
Mailing Address - Street 2:
Mailing Address - City:TRUMANSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14886-9527
Mailing Address - Country:US
Mailing Address - Phone:607-427-3939
Mailing Address - Fax:
Practice Address - Street 1:418 N TIOGA ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-5293
Practice Address - Country:US
Practice Address - Phone:607-427-3939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-31
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY086820104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY086820OtherLICENSED MASTER SOCIAL WORKER