Basic Information
Provider Information | |||||||||
NPI: | 1508868407 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BESTSELF BEHAVIORAL HEALTH, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 255 DELAWARE AVE | ||||||||
Address2: | SUITE 300 | ||||||||
City: | BUFFALO | ||||||||
State: | NY | ||||||||
PostalCode: | 142022016 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7168420440 | ||||||||
FaxNumber: | 7168424069 | ||||||||
Practice Location | |||||||||
Address1: | 255 DELAWARE AVE | ||||||||
Address2: |   | ||||||||
City: | BUFFALO | ||||||||
State: | NY | ||||||||
PostalCode: | 142022016 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7168420440 | ||||||||
FaxNumber: | 7168424069 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/11/2005 | ||||||||
LastUpdateDate: | 10/09/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WOIKE-GANGA | ||||||||
AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
AuthorizedOfficialTelephone: | 7168420440 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | LCSW-R | ||||||||
NPICertificationDate: | 10/09/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 080510843 | NY | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | 6783100A | NY | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 261QM0801X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
ID | Type | State | Issuer | Description | 00671765 | 05 | NY |   | MEDICAID |