Basic Information
| Provider Information | |||||||||
| NPI: | 1205198660 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HCA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18 BROAD ST | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 137902106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077987117 | ||||||||
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| Practice Location | |||||||||
| Address1: | 18 BROAD ST | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 137902106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077987117 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2012 | ||||||||
| LastUpdateDate: | 06/12/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BRESLIN | ||||||||
| AuthorizedOfficialFirstName: | CHRISTINE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CLINICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6077987117 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 252Y00000X | Y | Agencies | Early Intervention Provider Agency |
No ID Information.