Basic Information
Provider Information | |||||||||
NPI: | 1679698286 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MENTAL HEALTH SERVICES-ERIE COUNTY NORTHWEST CORPORATION I | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ENVISION WELLNESS WNY BEHAVIORAL HEALTH | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 710 | ||||||||
Address2: |   | ||||||||
City: | KENMORE | ||||||||
State: | NY | ||||||||
PostalCode: | 142170710 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7168822127 | ||||||||
FaxNumber: | 7168829277 | ||||||||
Practice Location | |||||||||
Address1: | 2495 ELMWOOD AVE | ||||||||
Address2: |   | ||||||||
City: | KENMORE | ||||||||
State: | NY | ||||||||
PostalCode: | 142172222 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7168822127 | ||||||||
FaxNumber: | 7168829277 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/20/2007 | ||||||||
LastUpdateDate: | 01/31/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CHURCH | ||||||||
AuthorizedOfficialFirstName: | DANIEL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | FINANCE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 7168822127 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MBA | ||||||||
NPICertificationDate: | 01/31/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X |   |   | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
ID | Type | State | Issuer | Description | 02996876 | 05 | NY |   | MEDICAID | 01556472 | 05 | NY |   | MEDICAID |