Basic Information
| Provider Information | |||||||||
| NPI: | 1205378809 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BESTSELF BEHAVIORAL HEALTH, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 255 DELAWARE AVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142022016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168420440 | ||||||||
| FaxNumber: | 7168424069 | ||||||||
| Practice Location | |||||||||
| Address1: | 951 NIAGARA ST | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142132116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168840700 | ||||||||
| FaxNumber: | 7168840631 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2016 | ||||||||
| LastUpdateDate: | 10/09/2020 | ||||||||
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| AuthorizedOfficialLastName: | WOIKE-GANGA | ||||||||
| AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 7168420440 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LCSW-R | ||||||||
| NPICertificationDate: | 10/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 6783101A | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 00671765 | 05 | NY | MEDICAID |