Provider Demographics
NPI:1467239814
Name:HIDING PLACE INDIVIDUAL FAMILY AND MARRIAGE THERAPY PLLC
Entity Type:Organization
Organization Name:HIDING PLACE INDIVIDUAL FAMILY AND MARRIAGE THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:LMFT
Authorized Official - Phone:716-201-0522
Mailing Address - Street 1:1868 NIAGARA FALLS BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14150-6494
Mailing Address - Country:US
Mailing Address - Phone:716-201-0522
Mailing Address - Fax:
Practice Address - Street 1:1868 NIAGARA FALLS BLVD STE 103
Practice Address - Street 2:
Practice Address - City:TONAWANDA
Practice Address - State:NY
Practice Address - Zip Code:14150-6494
Practice Address - Country:US
Practice Address - Phone:716-201-0522
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-11
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty