Basic Information
| Provider Information | |||||||||
| NPI: | 1053408807 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FLYNN | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSWR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1526 WALDEN AVENUE | ||||||||
| Address2: | |||||||||
| City: | CHEEKTOWAGA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168956700 | ||||||||
| FaxNumber: | 7168960318 | ||||||||
| Practice Location | |||||||||
| Address1: | 1526 WALDEN AVENUE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | CHEEKTOWAGA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168956700 | ||||||||
| FaxNumber: | 7168960318 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 11/25/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 038456-1 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 038456-1 | 01 | NY | LCSW-R | OTHER |