Basic Information
| Provider Information | |||||||||
| NPI: | 1588602064 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COUNTY OF GENESEE COUNTY TREASURER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | GENESEE COUNTY MENTAL HEALTH SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 5130 EAST MAIN STREET ROAD | ||||||||
| Address2: | STE 2 | ||||||||
| City: | BATAVIA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140203496 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853441421 | ||||||||
| FaxNumber: | 5853443047 | ||||||||
| Practice Location | |||||||||
| Address1: | 5130 EAST MAIN STREET ROAD | ||||||||
| Address2: | STE 2 | ||||||||
| City: | BATAVIA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140203496 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853441421 | ||||||||
| FaxNumber: | 5853443047 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2006 | ||||||||
| LastUpdateDate: | 02/24/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DAMIAN | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5853441421 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | BA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 00357497 | 05 | NY | MEDICAID | 01165017 | 05 | NY | MEDICAID | 01333068 | 05 | NY | MEDICAID |