Provider Demographics
NPI:1053453886
Name:CHILDREN'S HOME OF JEFFERSON COUNTY
Entity Type:Organization
Organization Name:CHILDREN'S HOME OF JEFFERSON COUNTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIANNE
Authorized Official - Middle Name:L
Authorized Official - Last Name:DIMATTEO
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:315-788-7430
Mailing Address - Street 1:PO BOX 6550
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-6550
Mailing Address - Country:US
Mailing Address - Phone:315-788-7430
Mailing Address - Fax:315-785-5637
Practice Address - Street 1:1704 STATE STREET
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601
Practice Address - Country:US
Practice Address - Phone:315-788-7430
Practice Address - Fax:315-785-5637
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY00009545322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00487210Medicaid