Provider Demographics
NPI:1003549130
Name:ST. JOSEPH'S ADDICTION TREATMENT & RECOVERY CENTERS
Entity Type:Organization
Organization Name:ST. JOSEPH'S ADDICTION TREATMENT & RECOVERY CENTERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PROVOST
Authorized Official - Suffix:
Authorized Official - Credentials:PEER SPECIALISTS
Authorized Official - Phone:518-357-8387
Mailing Address - Street 1:159 GLENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SARANAC LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12983-2385
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:917 CONGRESS ST
Practice Address - Street 2:
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12303-1727
Practice Address - Country:US
Practice Address - Phone:518-357-8387
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST JOSEPHS REHABILITATION CENTER, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-07-06
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty