Basic Information
| Provider Information | |||||||||
| NPI: | 1558578393 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNITED CEREBRAL PALSY ASSOC OF PUTNAM & SOUTHERN DUTCHESS | ||||||||
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| OtherOrganizationName: | UCP NYS WATERMELON HILL ICF | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 40 JON BARRETT RD | ||||||||
| Address2: | |||||||||
| City: | PATTERSON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125632164 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 265 WATERMELON HILL RD | ||||||||
| Address2: | |||||||||
| City: | MAHOPAC | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105414443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8458789078 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2007 | ||||||||
| LastUpdateDate: | 05/13/2015 | ||||||||
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| AuthorizedOfficialLastName: | YAGER | ||||||||
| AuthorizedOfficialFirstName: | HOWARD | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8458789078 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 315P00000X | Y | Nursing & Custodial Care Facilities | Intermediate Care Facility, Mentally Retarded |
ID Information
| ID | Type | State | Issuer | Description | 01214644 | 05 | NY | MEDICAID |