Basic Information
| Provider Information | |||||||||
| NPI: | 1962916460 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UCPA OF NIAGARA COUNTY, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | EMPOWER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 9812 LOCKPORT RD | ||||||||
| Address2: | |||||||||
| City: | NIAGARA FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 143041114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7162970798 | ||||||||
| FaxNumber: | 7162970998 | ||||||||
| Practice Location | |||||||||
| Address1: | 9812 LOCKPORT RD | ||||||||
| Address2: | |||||||||
| City: | NIAGARA FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 143041114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7162970798 | ||||||||
| FaxNumber: | 7162970998 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2017 | ||||||||
| LastUpdateDate: | 06/16/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MANGUS | ||||||||
| AuthorizedOfficialFirstName: | NANCY | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | BUDGET MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7162970798 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | N | Agencies | Case Management | 253Z00000X | N | Agencies | In Home Supportive Care | 235500000X | Y | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Specialist/Technologist |
ID Information
| ID | Type | State | Issuer | Description | 1871647974 | 05 | NY | MEDICAID | 1922246420 | 05 | NY | MEDICAID | 1073667176 | 05 | NY | MEDICAID | 1669526745 | 05 | NY | MEDICAID | 1124459383 | 05 | NY | MEDICAID | 1265586556 | 05 | NY | MEDICAID | 1780738880 | 05 | NY | MEDICAID |