Provider Demographics
NPI:1093980856
Name:MENTAL HEALTH SERVICES OF ERIE COUNTY SECV
Entity Type:Organization
Organization Name:MENTAL HEALTH SERVICES OF ERIE COUNTY SECV
Other - Org Name:SPECTRUM HUMAN SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:NISBET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-662-2040
Mailing Address - Street 1:227 THORN AVE
Mailing Address - Street 2:BOX 631
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-2600
Mailing Address - Country:US
Mailing Address - Phone:716-662-2040
Mailing Address - Fax:716-662-0019
Practice Address - Street 1:2040 SENECA ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14210-2324
Practice Address - Country:US
Practice Address - Phone:716-828-0560
Practice Address - Fax:716-828-1522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-23
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6845102A251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY8401220OtherIHA
NY040727000154OtherMEDICAID MANAGED CARE
NY00660577Medicaid
NY0001122770OtherUNIVERA
NY000507634001OtherBCBS
NY076341Medicare PIN