Basic Information
| Provider Information | |||||||||
| NPI: | 1538688924 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRESENCE PSYCHOLOGY, LMSW, PT, OT AND SLP SERVICES, PLLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PRESENCE DEVELOPMENTAL SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 115 FALL ST | ||||||||
| Address2: | |||||||||
| City: | SENECA FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 131481498 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3155155183 | ||||||||
| FaxNumber: | 3155155194 | ||||||||
| Practice Location | |||||||||
| Address1: | 115 FALL ST | ||||||||
| Address2: | |||||||||
| City: | SENECA FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 131481498 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3155155183 | ||||||||
| FaxNumber: | 3155155194 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | SEALY | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 3155155183 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LMSW | ||||||||
| NPICertificationDate: | 02/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 020699-1 | NY | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 235Z00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 103TM1800X | 020001-1 | NY | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Mental Retardation & Developmental Disabilities |
ID Information
| ID | Type | State | Issuer | Description | 05438899 | 05 | NY | MEDICAID |