Basic Information
| Provider Information | |||||||||
| NPI: | 1669079539 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CZERMERYS | ||||||||
| FirstName: | KINGSLEY | ||||||||
| MiddleName: | CLAY | ||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CZERMERYS | ||||||||
| OtherFirstName: | KATHERINE | ||||||||
| OtherMiddleName: | TOIREASA | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 25 WILLOWBROOK RD | ||||||||
| Address2: | |||||||||
| City: | QUEENSBURY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128045882 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5189267200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 25 WILLOWBROOK RD | ||||||||
| Address2: | |||||||||
| City: | QUEENSBURY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128045882 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5189267200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2020 | ||||||||
| LastUpdateDate: | 04/08/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.