Provider Demographics
NPI:1255997623
Name:FRY, ALICIA JANE (LMSW)
Entity type:Individual
Prefix:MS
First Name:ALICIA
Middle Name:JANE
Last Name:FRY
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:MS
Other - First Name:ALICIA
Other - Middle Name:JANE
Other - Last Name:WILTSEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:18419 50TH AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365-1601
Mailing Address - Country:US
Mailing Address - Phone:718-357-0459
Mailing Address - Fax:
Practice Address - Street 1:8802 ROCKAWAY BEACH BLVD
Practice Address - Street 2:
Practice Address - City:ROCKAWAY BEACH
Practice Address - State:NY
Practice Address - Zip Code:11693-1609
Practice Address - Country:US
Practice Address - Phone:718-634-3461
Practice Address - Fax:718-851-3470
Is Sole Proprietor?:No
Enumeration Date:2019-05-11
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY079788-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY079788-1OtherNEW YORK STATE DEPARTMENT OF EDUCATION-LICENSED MASTER SOCIAL WORKER