Basic Information
| Provider Information | |||||||||
| NPI: | 1306299821 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUMMIT EDUCATIONAL RESOURCES, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | THE SUMMIT CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 150 STAHL RD | ||||||||
| Address2: | |||||||||
| City: | GETZVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140681231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166293400 | ||||||||
| FaxNumber: | 7166293497 | ||||||||
| Practice Location | |||||||||
| Address1: | 150 STAHL RD | ||||||||
| Address2: | |||||||||
| City: | GETZVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140681231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166293400 | ||||||||
| FaxNumber: | 7166293497 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2016 | ||||||||
| LastUpdateDate: | 07/20/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JABLONSKI | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | VP, EDUCATION AND BEHAVIORAL HEALTH | ||||||||
| AuthorizedOfficialTelephone: | 7166293447 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PSY.D | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | NY | Y | Agencies | Case Management |
ID Information
| ID | Type | State | Issuer | Description | 02592143 | 05 | NY | MEDICAID | 02088457 | 05 | NY | MEDICAID | 02367040 | 05 | NY | MEDICAID | 02548438 | 05 | NY | MEDICAID | 02004213 | 05 | NY | MEDICAID | 01818482 | 05 | NY | MEDICAID |