Basic Information
Provider Information | |||||||||
NPI: | 1316196603 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CATHOLIC CHARITIES COMMUNITY SERVICES OF ORANGE COUNTY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 224 MAIN ST | ||||||||
Address2: | 2ND FLOOR | ||||||||
City: | GOSHEN | ||||||||
State: | NY | ||||||||
PostalCode: | 109242157 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8452945124 | ||||||||
FaxNumber: | 8452941369 | ||||||||
Practice Location | |||||||||
Address1: | 280 BROADWAY | ||||||||
Address2: | LOWER LEVEL | ||||||||
City: | NEWBURGH | ||||||||
State: | NY | ||||||||
PostalCode: | 125505408 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8455628255 | ||||||||
FaxNumber: | 8455624140 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/11/2008 | ||||||||
LastUpdateDate: | 09/11/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SCHER | ||||||||
AuthorizedOfficialFirstName: | DEAN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 8452945124 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | PH.D, L.C.S.W. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | 090111580 | NY | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
ID | Type | State | Issuer | Description | 02739311 | 05 | NY |   | MEDICAID |