Provider Demographics
NPI:1487956975
Name:QUACKENBUSH, VIRGINIA BERTSCH (LMSW)
Entity type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:BERTSCH
Last Name:QUACKENBUSH
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:471 PENNSYLVANIA AVE
Mailing Address - Street 2:TLC/BOCES
Mailing Address - City:APALACHIN
Mailing Address - State:NY
Mailing Address - Zip Code:13732-2501
Mailing Address - Country:US
Mailing Address - Phone:607-748-8261
Mailing Address - Fax:607-748-8262
Practice Address - Street 1:471 PENNSYLVANIA AVE
Practice Address - Street 2:TLC/BOCES
Practice Address - City:APALACHIN
Practice Address - State:NY
Practice Address - Zip Code:13732-2501
Practice Address - Country:US
Practice Address - Phone:607-748-8261
Practice Address - Fax:607-748-8262
Is Sole Proprietor?:No
Enumeration Date:2010-12-03
Last Update Date:2010-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY062512-11041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool