Provider Demographics
NPI:1225725880
Name:SOUTHERN TIER NURSE PRACTITIONERS IN PSYCHIATRY
Entity Type:Organization
Organization Name:SOUTHERN TIER NURSE PRACTITIONERS IN PSYCHIATRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:CLINTON
Authorized Official - Middle Name:
Authorized Official - Last Name:GEORGE
Authorized Official - Suffix:
Authorized Official - Credentials:PMHDNP
Authorized Official - Phone:716-489-8850
Mailing Address - Street 1:141 CHAUTAUQUA AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:14750-1278
Mailing Address - Country:US
Mailing Address - Phone:716-489-8850
Mailing Address - Fax:
Practice Address - Street 1:141 CHAUTAUQUA AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NY
Practice Address - Zip Code:14750-1278
Practice Address - Country:US
Practice Address - Phone:716-489-8850
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-24
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health