Basic Information
| Provider Information | |||||||||
| NPI: | 1053453886 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHILDREN'S HOME OF JEFFERSON COUNTY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6550 | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136016550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157887430 | ||||||||
| FaxNumber: | 3157855637 | ||||||||
| Practice Location | |||||||||
| Address1: | 1704 STATE STREET | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157887430 | ||||||||
| FaxNumber: | 3157855637 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2007 | ||||||||
| LastUpdateDate: | 05/04/2016 | ||||||||
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| AuthorizedOfficialLastName: | RICHMOND | ||||||||
| AuthorizedOfficialFirstName: | KAREN | ||||||||
| AuthorizedOfficialMiddleName: | Y | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3157887430 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 322D00000X | 00009545 | NY | Y | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children |
ID Information
| ID | Type | State | Issuer | Description | 00487210 | 05 | NY | MEDICAID |