Basic Information
Provider Information | |||||||||
NPI: | 1285031252 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ACCESS: SUPPORTS FOR LIVING INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | OCCUPATIONS, INC. | ||||||||
OtherOrganizationType: | 4 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 15 FORTUNE RD W | ||||||||
Address2: |   | ||||||||
City: | MIDDLETOWN | ||||||||
State: | NY | ||||||||
PostalCode: | 109411625 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8456924454 | ||||||||
FaxNumber: | 8456928887 | ||||||||
Practice Location | |||||||||
Address1: | 15 FORTUNE RD W | ||||||||
Address2: |   | ||||||||
City: | MIDDLETOWN | ||||||||
State: | NY | ||||||||
PostalCode: | 109411625 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8456924454 | ||||||||
FaxNumber: | 8456928887 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/19/2014 | ||||||||
LastUpdateDate: | 01/02/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ANDERSON-WINCHELL | ||||||||
AuthorizedOfficialFirstName: | AMY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 8456924454 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | L.C.S.W. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 253Z00000X |   |   | N |   | Agencies | In Home Supportive Care |   | 251B00000X |   |   | Y |   | Agencies | Case Management |   |
ID Information
ID | Type | State | Issuer | Description | 01604448 | 05 | NY |   | MEDICAID | 01998732 | 05 | NY |   | MEDICAID | 02596069 | 05 | NY |   | MEDICAID | 02127851 | 05 | NY |   | MEDICAID | 01738485 | 05 | NY |   | MEDICAID | 02275643 | 05 | NY |   | MEDICAID | 02699416 | 05 | NY |   | MEDICAID | 03060717 | 05 | NY |   | MEDICAID |