Provider Demographics
NPI:1780790618
Name:WOLPERT, COLLEEN L (LCSWR)
Entity type:Individual
Prefix:MRS
First Name:COLLEEN
Middle Name:L
Last Name:WOLPERT
Suffix:
Gender:F
Credentials:LCSWR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:232 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13905-2610
Mailing Address - Country:US
Mailing Address - Phone:607-729-9166
Mailing Address - Fax:607-729-2062
Practice Address - Street 1:232 MAIN ST
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13905-2610
Practice Address - Country:US
Practice Address - Phone:607-729-9166
Practice Address - Fax:607-729-2062
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR050733-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
7406715OtherGHI EMPIRE VALUE OPTIONS
000024632OtherBCBS
618812OtherMVP
040426031570OtherFIDELITY
257880OtherCDPHP
257880OtherCDPHP
040426031570OtherFIDELITY