Basic Information
| Provider Information | |||||||||
| NPI: | 1669524492 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHILD AND ADOLESCENT TREATMENT SERVICE INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 CAYUGA ROAD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | CHEEKTOWAGA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142251950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168193420 | ||||||||
| FaxNumber: | 7168193430 | ||||||||
| Practice Location | |||||||||
| Address1: | 11 WEST MAIN STREET | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LANCASTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14086 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166816611 | ||||||||
| FaxNumber: | 7166816613 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2007 | ||||||||
| LastUpdateDate: | 01/05/2018 | ||||||||
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| AuthorizedOfficialLastName: | GLAZER | ||||||||
| AuthorizedOfficialFirstName: | BONNIE | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7168193420 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | LCSW ACSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 00357855 | 05 | NY | MEDICAID |