Basic Information
| Provider Information | |||||||||
| NPI: | 1679904437 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOLDTHWAIT | ||||||||
| FirstName: | JEAN | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 220 HERALD PL | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132025002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154727363 | ||||||||
| FaxNumber: | 3157012368 | ||||||||
| Practice Location | |||||||||
| Address1: | 220 HERALD PL | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132025002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154727363 | ||||||||
| FaxNumber: | 3157012368 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2013 | ||||||||
| LastUpdateDate: | 12/04/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 805716 | NY | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.