Provider Demographics
NPI:1114302247
Name:CATHOLIC CHARITIES DIOCESE OF ROCHESTER
Entity Type:Organization
Organization Name:CATHOLIC CHARITIES DIOCESE OF ROCHESTER
Other - Org Name:CATHOLIC CHARITIES OF LIVINGSTON COUNTY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TABITHA
Authorized Official - Middle Name:JON
Authorized Official - Last Name:BREWSTER
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:585-658-4466
Mailing Address - Street 1:34 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT MORRIS
Mailing Address - State:NY
Mailing Address - Zip Code:14510-9727
Mailing Address - Country:US
Mailing Address - Phone:585-658-4466
Mailing Address - Fax:585-658-2513
Practice Address - Street 1:34 E STATE ST
Practice Address - Street 2:
Practice Address - City:MOUNT MORRIS
Practice Address - State:NY
Practice Address - Zip Code:14510-9727
Practice Address - Country:US
Practice Address - Phone:585-658-4466
Practice Address - Fax:585-658-2513
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CATHOLIC CHARITIES OF THE DIOCESE OF ROCHESTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-07-30
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
No305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04439209Medicaid