Basic Information
| Provider Information | |||||||||
| NPI: | 1205193869 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOEDEKER | ||||||||
| FirstName: | CARA | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 NOYES ST | ||||||||
| Address2: | - YORK STREET | ||||||||
| City: | UTICA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 135023854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157384440 | ||||||||
| FaxNumber: | 3157384410 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 NOYES ST | ||||||||
| Address2: | - YORK STREET | ||||||||
| City: | UTICA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 135023854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157384440 | ||||||||
| FaxNumber: | 3157384410 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2012 | ||||||||
| LastUpdateDate: | 08/13/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | 73082734 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | 72082268 | NY | N | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 1295175867 | 01 | NY | AGENCY NPI | OTHER |