Provider Demographics
NPI:1477806545
Name:THE STRAWBERRY MANSION SOCIETY
Entity Type:Organization
Organization Name:THE STRAWBERRY MANSION SOCIETY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MONIQUE
Authorized Official - Middle Name:DANIELLE
Authorized Official - Last Name:GRAVATT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:607-846-3505
Mailing Address - Street 1:415 WILLIAM ST
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14901-2533
Mailing Address - Country:US
Mailing Address - Phone:607-846-3505
Mailing Address - Fax:607-216-3319
Practice Address - Street 1:415 WILLIAM ST
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14901-2533
Practice Address - Country:US
Practice Address - Phone:607-846-3505
Practice Address - Fax:607-216-3319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-26
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03128645Medicaid