Provider Demographics
NPI:1073989851
Name:THE NATIONAL WITNESS PROJECT, INC
Entity Type:Organization
Organization Name:THE NATIONAL WITNESS PROJECT, INC
Other - Org Name:THE NATIONAL WITNESS PROJECT, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROJECT DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DETRIC
Authorized Official - Middle Name:DEE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-550-6354
Mailing Address - Street 1:669 KENSINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14215-2644
Mailing Address - Country:US
Mailing Address - Phone:716-832-7566
Mailing Address - Fax:716-845-4069
Practice Address - Street 1:669 KENSINGTON AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14215-2644
Practice Address - Country:US
Practice Address - Phone:716-845-1389
Practice Address - Fax:716-845-4069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-17
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY=========Medicaid