Basic Information
| Provider Information | |||||||||
| NPI: | 1538455696 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHILDRENS HOME OF JEFFERSON COUNTY | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | COMMUNITY CLINIC OF JEFFERSON COUNTY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6550 | ||||||||
| Address2: | 1704 STATE STREET | ||||||||
| City: | WATERTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136016550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157887430 | ||||||||
| FaxNumber: | 3157855637 | ||||||||
| Practice Location | |||||||||
| Address1: | 167 POLK STREET | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | WATERTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136012770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157827445 | ||||||||
| FaxNumber: | 3157791184 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2011 | ||||||||
| LastUpdateDate: | 10/05/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RICHMOND | ||||||||
| AuthorizedOfficialFirstName: | KAREN | ||||||||
| AuthorizedOfficialMiddleName: | Y | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3157887430 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CHILDREN'S HOME OF JEFFERSON COUNTY | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 03A2861 | NY | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 251S00000X | 9298014A | NY | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 3372621 | 05 | NY | MEDICAID | 9298014A | 01 | NY | NEW YORK STATE OFFICE OF MENTAL HEALTH/OPERATING CERTIFICATE | OTHER |