Basic Information
| Provider Information | |||||||||
| NPI: | 1467895482 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TAVENIERE | ||||||||
| FirstName: | EILEEN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4788 EDGEWORTH DR | ||||||||
| Address2: | |||||||||
| City: | MANLIUS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 131042106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3156826944 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 200 W DOMINICK ST | ||||||||
| Address2: | |||||||||
| City: | ROME | ||||||||
| State: | NY | ||||||||
| PostalCode: | 134405838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153396536 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2013 | ||||||||
| LastUpdateDate: | 04/09/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 062100-1 | NY | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.