Basic Information
| Provider Information | |||||||||
| NPI: | 1780636506 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UPSTATE CEREBRAL PALSY, INC | ||||||||
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| OtherOrganizationName: | UNITED CEREBRAL PALSY & HANDICPPED PERSONS ASSN. | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1020 MARY ST | ||||||||
| Address2: | |||||||||
| City: | UTICA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 135011930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157246907 | ||||||||
| FaxNumber: | 3157330791 | ||||||||
| Practice Location | |||||||||
| Address1: | 1427 GENESEE ST | ||||||||
| Address2: | |||||||||
| City: | UTICA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 135014343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157381428 | ||||||||
| FaxNumber: | 3157337105 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 10/26/2018 | ||||||||
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| AuthorizedOfficialLastName: | DECONDO | ||||||||
| AuthorizedOfficialFirstName: | GENO | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3157246907 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 213E00000X | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | 261QD1600X | N | Ambulatory Health Care Facilities | Clinic/Center | Developmental Disabilities | 261QM0801X | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 315P00000X | N | Nursing & Custodial Care Facilities | Intermediate Care Facility, Mentally Retarded | 101YM0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 00474180 | 05 | NY | MEDICAID | 01039156 | 05 | NY | MEDICAID |