Basic Information
| Provider Information | |||||||||
| NPI: | 1346769734 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRESENCE SEALY COUNSELING AND DEVELOPMENT LICENSEDCLINICALSERVICESPLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 115 FALL ST | ||||||||
| Address2: | |||||||||
| City: | SENECA FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 131481498 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3155155183 | ||||||||
| FaxNumber: | 3155155194 | ||||||||
| Practice Location | |||||||||
| Address1: | 115 FALL ST | ||||||||
| Address2: | |||||||||
| City: | SENECA FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 131481498 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3155155183 | ||||||||
| FaxNumber: | 3155155194 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2017 | ||||||||
| LastUpdateDate: | 01/14/2021 | ||||||||
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| AuthorizedOfficialLastName: | SEALY | ||||||||
| AuthorizedOfficialFirstName: | JAMEE | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3155688894 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LCSW-R | ||||||||
| NPICertificationDate: | 01/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | R036144-1 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 05325920 | 05 | NY | MEDICAID |