Basic Information
| Provider Information | |||||||||
| NPI: | 1255053716 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALLEN | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | LAVELLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 238 ARSENAL ST | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136012504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157829450 | ||||||||
| FaxNumber: | 3157822643 | ||||||||
| Practice Location | |||||||||
| Address1: | 238 ARSENAL ST | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136012504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157829450 | ||||||||
| FaxNumber: | 3157822643 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2022 | ||||||||
| LastUpdateDate: | 09/13/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 09/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 117211 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 117211 | 01 | NY | LICENSE | OTHER |