Basic Information
| Provider Information | |||||||||
| NPI: | 1366637167 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTEGRATED BEHAVIORAL WELLNESS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 GATES RD | ||||||||
| Address2: | STE 3 | ||||||||
| City: | VESTAL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 138502288 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077729462 | ||||||||
| FaxNumber: | 6077721223 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 FOUNTAIN ST | ||||||||
| Address2: | STE 110 | ||||||||
| City: | CLINTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 133231725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153813101 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2007 | ||||||||
| LastUpdateDate: | 09/14/2007 | ||||||||
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| AuthorizedOfficialLastName: | KLEIN | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3153813101 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 052946 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.