Basic Information
| Provider Information | |||||||||
| NPI: | 1639391139 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SCIAVOLINO | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 CRESCENT AVE. | ||||||||
| Address2: | |||||||||
| City: | SARATOGA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 12866 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 30 CRESCENT AVE. | ||||||||
| Address2: | |||||||||
| City: | SARATOGA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 12866 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5185843600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | R-029032-1 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 131974 | 01 | NY | VALUE OPTIONS | OTHER |