Provider Demographics
NPI:1427228477
Name:KINGSBURY, ERIC THOMAS (CASAC T)
Entity Type:Individual
Prefix:MR
First Name:ERIC
Middle Name:THOMAS
Last Name:KINGSBURY
Suffix:
Gender:M
Credentials:CASAC T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 TUSCARORA RD
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14220-2028
Mailing Address - Country:US
Mailing Address - Phone:716-572-2479
Mailing Address - Fax:
Practice Address - Street 1:3020 BAILEY AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14215-2814
Practice Address - Country:US
Practice Address - Phone:716-833-3622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-05
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY21569101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY101YA0400XMedicare PIN