Basic Information
| Provider Information | |||||||||
| NPI: | 1063668325 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALLEGANY REHABILITATION ASSOCIATES, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | WYO. CO. CHEMICAL ABUSE TX PROGRAM | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 422 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WARSAW | ||||||||
| State: | NY | ||||||||
| PostalCode: | 145691023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5857868133 | ||||||||
| FaxNumber: | 5857869928 | ||||||||
| Practice Location | |||||||||
| Address1: | 422 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WARSAW | ||||||||
| State: | NY | ||||||||
| PostalCode: | 145691023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5857868133 | ||||||||
| FaxNumber: | 5857869928 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2008 | ||||||||
| LastUpdateDate: | 08/18/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MANN | ||||||||
| AuthorizedOfficialFirstName: | BARBARA | ||||||||
| AuthorizedOfficialMiddleName: | JEAN | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5857868133 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 02977071 | 05 | NY | MEDICAID |