Basic Information
Provider Information
NPI: 1003003369
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: ZENTZ
FirstName: TATIANA
MiddleName: MILDRED
NamePrefix: MRS.
NameSuffix:  
Credential: MSED.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 41
Address2:  
City: SILVER LAKE
State: NY
PostalCode: 145490041
CountryCode: US
TelephoneNumber: 5855070106
FaxNumber:  
Practice Location
Address1: 422 N MAIN ST
Address2:  
City: WARSAW
State: NY
PostalCode: 145691023
CountryCode: US
TelephoneNumber: 5857868133
FaxNumber: 5857869928
Other Information
ProviderEnumerationDate: 10/01/2007
LastUpdateDate: 10/01/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101YA0400X  Y Behavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)

ID Information
IDTypeStateIssuerDescription
0074042305NY MEDICAID


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