Basic Information
| Provider Information | |||||||||
| NPI: | 1619238524 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BESAW | ||||||||
| FirstName: | HOLLY | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HOWARD | ||||||||
| OtherFirstName: | HOLLY | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MS | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 216 COUNTY ROUTE 64 | ||||||||
| Address2: | |||||||||
| City: | MEXICO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 131143229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3159633680 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 216 COUNTY ROUTE 64 | ||||||||
| Address2: | |||||||||
| City: | MEXICO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 131143229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3159633680 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2012 | ||||||||
| LastUpdateDate: | 06/06/2012 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator | 174400000X | NY | N | Other Service Providers | Specialist |
No ID Information.