Basic Information
| Provider Information | |||||||||
| NPI: | 1922525757 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CAWLEY | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | |||||||||
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| Credential: | LMSW, CASAC-T | ||||||||
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| Mailing Information | |||||||||
| Address1: | 79 GLENRIDGE RD | ||||||||
| Address2: | |||||||||
| City: | GLENVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 123024523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5189528408 | ||||||||
| FaxNumber: | 5183996860 | ||||||||
| Practice Location | |||||||||
| Address1: | 8002 KEW GARDENS RD STE 704 | ||||||||
| Address2: | |||||||||
| City: | KEW GARDENS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114153607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7185201513 | ||||||||
| FaxNumber: | 7185206460 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2017 | ||||||||
| LastUpdateDate: | 08/23/2017 | ||||||||
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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 | 104100000X | 100967 | NY | N | Behavioral Health & Social Service Providers | Social Worker | 101YA0400X | 33672 | NY | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 01420795 | 05 | NY | MEDICAID |