Basic Information
| Provider Information | |||||||||
| NPI: | 1225095201 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MID ERIE MENTAL HEALTH SERVICES INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MID ERIE COUNSELING AND TREATMENT SERVICES | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1526 WALDEN AVE | ||||||||
| Address2: | STE 400 | ||||||||
| City: | CHEEKTOWAGA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142254965 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168957167 | ||||||||
| FaxNumber: | 7163824488 | ||||||||
| Practice Location | |||||||||
| Address1: | 1526 WALDEN AVE | ||||||||
| Address2: | STE 400 | ||||||||
| City: | CHEEKTOWAGA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142254965 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168957167 | ||||||||
| FaxNumber: | 7163824488 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2006 | ||||||||
| LastUpdateDate: | 10/09/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCINERNEY | ||||||||
| AuthorizedOfficialFirstName: | PATRICK | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7168957167 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CPA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 104100000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | 101Y00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 000506023001 | 01 | COMMUNITY BLUE | OTHER | 000507788006 | 01 | BLUE CROSS MENTAL HEALTH | OTHER | 000525284002 | 01 | BLUE CROSS MENTAL HEALTH | OTHER | 000528870001 | 01 | PPO BLUE CROSS MENTAL H | OTHER | 0029795 | 01 | GHI | OTHER | 8401019 | 01 | IHA | OTHER | 00011241001 | 01 | UNIVERA MEDICAL DOCTOR | OTHER | 000525283001 | 01 | BLUE CROSS MENTAL HEALTH | OTHER | 1131 | 01 | BLUE CROSS CHD | OTHER | 000524043001 | 01 | BLUE CROSS MENTAL HEALTH | OTHER | 000000859000 | 01 | PPO BLUE CROSS | OTHER | 000500635005 | 01 | BLUE CROSS MENTAL HEALTH | OTHER | 000000858000 | 01 | PPO BLUE CROSS | OTHER | 000081002150 | 01 | FIDELIS | OTHER | 000000809000 | 01 | PPO BLUE CROSS | OTHER | 1526 | 01 | BLUE CROSS CHD | OTHER | 000504008007 | 01 | BLUE CROSS MENTAL HEALTH | OTHER | 463 | 01 | BLUE CROSS CHD | OTHER |