Provider Demographics
NPI:1093875007
Name:CATHOLIC CHARITIES OF ORANGE, SULLIVAN & ULSTER
Entity Type:Organization
Organization Name:CATHOLIC CHARITIES OF ORANGE, SULLIVAN & ULSTER
Other - Org Name:CATHOLIC CHARITIES COMMUNITY SERVICES OF ORANGE COUNTY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-294-5124
Mailing Address - Street 1:27 MATTHEWS STREET
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:NY
Mailing Address - Zip Code:10924
Mailing Address - Country:US
Mailing Address - Phone:845-294-5124
Mailing Address - Fax:845-294-1369
Practice Address - Street 1:27 MATTHEWS STREET
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:NY
Practice Address - Zip Code:10924
Practice Address - Country:US
Practice Address - Phone:845-294-5124
Practice Address - Fax:845-294-1369
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY070111579261QR0405X
261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02739311Medicaid
NY02739311Medicaid