Basic Information
| Provider Information | |||||||||
| NPI: | 1659651321 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH COUNTRY CHILDREN'S CLINIC, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 238 ARSENAL ST | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136012504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157829450 | ||||||||
| FaxNumber: | 3157822643 | ||||||||
| Practice Location | |||||||||
| Address1: | 13180 US ROUTE 11 | ||||||||
| Address2: | |||||||||
| City: | ADAMS CENTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136062276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3155835200 | ||||||||
| FaxNumber: | 3155835255 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2011 | ||||||||
| LastUpdateDate: | 08/25/2011 | ||||||||
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| AuthorizedOfficialLastName: | MARTIN | ||||||||
| AuthorizedOfficialFirstName: | AILEEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3157829450 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 080061-1 | NY | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 00583702 | 05 | NY | MEDICAID |