Provider Demographics
NPI:1619248762
Name:MOUNTAIN COMMUNITY WELLNESS CENTER
Entity Type:Organization
Organization Name:MOUNTAIN COMMUNITY WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-R
Authorized Official - Phone:315-221-4381
Mailing Address - Street 1:210 COURT ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-4546
Mailing Address - Country:US
Mailing Address - Phone:315-221-4381
Mailing Address - Fax:315-221-4382
Practice Address - Street 1:210 COURT ST
Practice Address - Street 2:SUITE 4
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-4546
Practice Address - Country:US
Practice Address - Phone:315-221-4381
Practice Address - Fax:315-221-4382
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-21
Last Update Date:2012-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0619251041C0700X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty