Basic Information
Provider Information | |||||||||
NPI: | 1528174976 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ACCESS: SUPPORTS FOR LIVING INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | OCCUPATIONS INC | ||||||||
OtherOrganizationType: | 4 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 15 FORTUNE ROAD WEST | ||||||||
Address2: |   | ||||||||
City: | MIDDLETOWN | ||||||||
State: | NY | ||||||||
PostalCode: | 10941 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8456924454 | ||||||||
FaxNumber: | 8456928887 | ||||||||
Practice Location | |||||||||
Address1: | 15 FORTUNE ROAD WEST | ||||||||
Address2: |   | ||||||||
City: | MIDDLETOWN | ||||||||
State: | NY | ||||||||
PostalCode: | 10941 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8456924454 | ||||||||
FaxNumber: | 8456928887 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/21/2006 | ||||||||
LastUpdateDate: | 01/02/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ANDERSON-WINCHELL | ||||||||
AuthorizedOfficialFirstName: | AMY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 8456924454 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | LCSW | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
ID | Type | State | Issuer | Description | 00911188 | 05 | NY |   | MEDICAID | 4576169 | 01 |   | AETNA INSURANCE | OTHER | 110132500 | 01 |   | ACS | OTHER | 01324730 | 05 | NY |   | MEDICAID | 7025098 | 01 |   | AETNA INSURANCE | OTHER | 7686768 | 01 |   | AETNA INSURANCE | OTHER | 965762A | 01 |   | MVP INSURANCE | OTHER | 01189019 | 05 | NY |   | MEDICAID | 02170203 | 05 | NY |   | MEDICAID | 319122299 | 01 |   | GHI VALUE OPTIONS | OTHER | 1018450 | 01 |   | BEACON HEALTH INS COMPANY | OTHER | 00275085 | 05 | NY |   | MEDICAID | 7209729 | 01 |   | AETNA INSURANCE | OTHER | 7360125 | 01 |   | AETNA INSURANCE | OTHER | 965762 | 01 |   | MVP INSURANCE | OTHER |