Provider Demographics
NPI:1598820359
Name:WINDHAM ASHLAND JEWETT CSD
Entity Type:Organization
Organization Name:WINDHAM ASHLAND JEWETT CSD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-734-4229
Mailing Address - Street 1:P.O. BOX 429
Mailing Address - Street 2:
Mailing Address - City:WINDHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12496
Mailing Address - Country:US
Mailing Address - Phone:518-734-4229
Mailing Address - Fax:518-734-6050
Practice Address - Street 1:5411 STATE ROUTE 23
Practice Address - Street 2:
Practice Address - City:WINDHAM
Practice Address - State:NY
Practice Address - Zip Code:12496
Practice Address - Country:US
Practice Address - Phone:518-734-4229
Practice Address - Fax:518-734-6050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-22
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01381960Medicaid