Basic Information
| Provider Information | |||||||||
| NPI: | 1225210677 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MENTAL HEALTH SERVICES OF ERIE COUNTY, SOUTHEAST CORP. V | ||||||||
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| OtherOrganizationName: | SPECTRUM HUMAN SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 227 THORN AVE | ||||||||
| Address2: | BOX 631 | ||||||||
| City: | ORCHARD PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 141272600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166622040 | ||||||||
| FaxNumber: | 7166620019 | ||||||||
| Practice Location | |||||||||
| Address1: | 1280 MAIN ST | ||||||||
| Address2: | THIRD FLOOR | ||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142091912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168426713 | ||||||||
| FaxNumber: | 7168420988 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2007 | ||||||||
| LastUpdateDate: | 11/28/2007 | ||||||||
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| AuthorizedOfficialLastName: | NISBET | ||||||||
| AuthorizedOfficialFirstName: | BRUCE | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 7166622040 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 2717531 | 05 | NY | MEDICAID |