Basic Information
Provider Information | |||||||||
NPI: | 1194882316 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NYS OFFICE OF MENTAL HEALTH | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ELMIRA PSYCHIATRIC CENTER | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 44 HOLLAND AVE | ||||||||
Address2: |   | ||||||||
City: | ALBANY | ||||||||
State: | NY | ||||||||
PostalCode: | 122290001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5184738234 | ||||||||
FaxNumber: | 5184735167 | ||||||||
Practice Location | |||||||||
Address1: | 100 WASHINGTON ST | ||||||||
Address2: |   | ||||||||
City: | ELMIRA | ||||||||
State: | NY | ||||||||
PostalCode: | 149012849 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6077374739 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/03/2007 | ||||||||
LastUpdateDate: | 04/19/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GIARRUSSO | ||||||||
AuthorizedOfficialFirstName: | BETH | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR, FINANCE | ||||||||
AuthorizedOfficialTelephone: | 5184733598 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X |   | NY | N |   | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 3336S0011X |   | NY | N |   | Suppliers | Pharmacy | Specialty Pharmacy | 261QM0850X |   | NY | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
ID Information
ID | Type | State | Issuer | Description | 00769420 | 05 | NY |   | MEDICAID | 02712036 | 05 | NY |   | MEDICAID |