Provider Demographics
NPI:1205003613
Name:THE CHILDREN'S HOME OF KINGSTON NY
Entity Type:Organization
Organization Name:THE CHILDREN'S HOME OF KINGSTON NY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR, CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:GWENDOLYN
Authorized Official - Middle Name:B
Authorized Official - Last Name:MCCANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-331-1448
Mailing Address - Street 1:26 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-3334
Mailing Address - Country:US
Mailing Address - Phone:845-331-1448
Mailing Address - Fax:845-334-9507
Practice Address - Street 1:26 GROVE ST
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-3334
Practice Address - Country:US
Practice Address - Phone:845-331-1448
Practice Address - Fax:845-334-9507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-14
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY322D00000X322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00353342Medicaid