Basic Information
| Provider Information | |||||||||
| NPI: | 1477667137 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MADISON COUNTY MENTAL HEALTH DEPARTMENT-CEDAR HOUSE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 CEDAR ST | ||||||||
| Address2: | |||||||||
| City: | ONEIDA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 134212111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153618413 | ||||||||
| FaxNumber: | 3153618450 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 CEDAR ST | ||||||||
| Address2: | |||||||||
| City: | ONEIDA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 134212111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153618413 | ||||||||
| FaxNumber: | 3153618450 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | KLEINKLAUS | ||||||||
| AuthorizedOfficialFirstName: | TOM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PROGRAM DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3153618413 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | LMSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 6873300A | NY | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 00569860 | 05 | NY | MEDICAID |