Provider Demographics
NPI:1285840074
Name:SOUTHERN TIER INDEPENDENCE CENTER, INC.
Entity Type:Organization
Organization Name:SOUTHERN TIER INDEPENDENCE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:607-724-2111
Mailing Address - Street 1:135 E FREDERICK ST
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13904-1224
Mailing Address - Country:US
Mailing Address - Phone:607-724-2111
Mailing Address - Fax:
Practice Address - Street 1:135 E FREDERICK ST
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13904-1224
Practice Address - Country:US
Practice Address - Phone:607-724-2111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No251E00000XAgenciesHome Health
No251X00000XAgenciesSupports Brokerage
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02516310Medicaid
NY02003001Medicaid
NY01543122Medicaid
NY02693649Medicaid
NY01741166Medicaid
NY02168761Medicaid
NY02625478Medicaid
NY01489734Medicaid