Basic Information
| Provider Information | |||||||||
| NPI: | 1962570820 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ENIGK | ||||||||
| FirstName: | TANYA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW-R | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GILLEECE | ||||||||
| OtherFirstName: | TANYA | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LCSW-R | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 332 ROBERTSON RD | ||||||||
| Address2: | |||||||||
| City: | SHERRILL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 134611367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157622144 | ||||||||
| FaxNumber: | 3153639286 | ||||||||
| Practice Location | |||||||||
| Address1: | 5457 EAST SENECA STREET | ||||||||
| Address2: | |||||||||
| City: | VERNON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13476 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157622144 | ||||||||
| FaxNumber: | 3153639286 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2006 | ||||||||
| LastUpdateDate: | 04/08/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 0710921 | NY | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | 73071092 | NY | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 0720007192 | 05 | NY | MEDICAID |