Basic Information
| Provider Information | |||||||||
| NPI: | 1467824656 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST LAWRENCE PSY CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 CHIMNEY POINT DR | ||||||||
| Address2: | |||||||||
| City: | OGDENSBURG | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136692212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3155412001 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2155 ST RT 22B | ||||||||
| Address2: | |||||||||
| City: | MORRISONVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 129623417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5185638000 | ||||||||
| FaxNumber: | 1518563900 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2015 | ||||||||
| LastUpdateDate: | 10/27/2015 | ||||||||
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| AuthorizedOfficialLastName: | CAVENEE | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | INTENSIVE CASE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5185698990 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | M.ED | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 305S00000X | Y | Managed Care Organizations | Point of Service |
No ID Information.