Provider Demographics
NPI:1033821210
Name:NORTH COUNTRY PSYCHOLOGICAL SERVICES
Entity Type:Organization
Organization Name:NORTH COUNTRY PSYCHOLOGICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DESIREE
Authorized Official - Middle Name:A
Authorized Official - Last Name:LEBOEUF
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:315-261-9210
Mailing Address - Street 1:74 STATE ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:NY
Mailing Address - Zip Code:13617-1026
Mailing Address - Country:US
Mailing Address - Phone:315-261-9210
Mailing Address - Fax:
Practice Address - Street 1:42 1/2 ELM ST
Practice Address - Street 2:
Practice Address - City:POTSDAM
Practice Address - State:NY
Practice Address - Zip Code:13676-1813
Practice Address - Country:US
Practice Address - Phone:315-261-9210
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-19
Last Update Date:2024-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY07748561Medicaid
NY022976OtherNYS DEPT. OF EDU.