Basic Information
| Provider Information | |||||||||
| NPI: | 1942787700 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NORTZ-MILLER | ||||||||
| FirstName: | CHARITY | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MSW INTERN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NORTZ | ||||||||
| OtherFirstName: | CHARITY | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 6550 | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136016550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157827445 | ||||||||
| FaxNumber: | 3157791184 | ||||||||
| Practice Location | |||||||||
| Address1: | 167 POLK ST STE 300 | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136012770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157827445 | ||||||||
| FaxNumber: | 3157791184 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2018 | ||||||||
| LastUpdateDate: | 07/25/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | 3372621 | 05 | NY | MEDICAID |