Basic Information
Provider Information | |||||||||
NPI: | 1881860633 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | UPSTATECEREBRAL PALSY, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | UNITED CEREBRAL PALSY | ||||||||
OtherOrganizationType: | 4 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1020 MARY ST | ||||||||
Address2: |   | ||||||||
City: | UTICA | ||||||||
State: | NY | ||||||||
PostalCode: | 135011930 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3157246907 | ||||||||
FaxNumber: | 3157330791 | ||||||||
Practice Location | |||||||||
Address1: | 10708 N GAGE RD | ||||||||
Address2: |   | ||||||||
City: | BARNEVELD | ||||||||
State: | NY | ||||||||
PostalCode: | 133042527 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3158962654 | ||||||||
FaxNumber: | 3158962864 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/01/2008 | ||||||||
LastUpdateDate: | 10/26/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DECONDO | ||||||||
AuthorizedOfficialFirstName: | GENO | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 3157246907 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320900000X | 6282300 | NY | Y |   | Residential Treatment Facilities | Community Based Residential Treatment, Mental Retardation and/or Developmental Disabilities |   |
ID Information
ID | Type | State | Issuer | Description | 00807983 | 05 | NY |   | MEDICAID |