Provider Demographics
NPI:1619059052
Name:CREEDMOOR ADDICTION TREATMENT CENTER
Entity Type:Organization
Organization Name:CREEDMOOR ADDICTION TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE COMMISSIONER, DIVISION OF
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:LAWLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-457-5312
Mailing Address - Street 1:80 45 WINCHESTER BOULEVARD
Mailing Address - Street 2:BUILDING 19 CBU 15
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11427
Mailing Address - Country:US
Mailing Address - Phone:718-264-3740
Mailing Address - Fax:718-776-5145
Practice Address - Street 1:80 45 WINCHESTER BOULEVARD
Practice Address - Street 2:BUILDING 19 CBU 15
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11427
Practice Address - Country:US
Practice Address - Phone:718-264-3740
Practice Address - Fax:718-776-5145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01438233Medicaid