Provider Demographics
NPI:1639215064
Name:NORTHERN NEW YORK CEREBRAL PALSY ASSOCIATION
Entity Type:Organization
Organization Name:NORTHERN NEW YORK CEREBRAL PALSY ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:L
Authorized Official - Last Name:BRABANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-788-5650
Mailing Address - Street 1:714 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-4032
Mailing Address - Country:US
Mailing Address - Phone:315-788-5650
Mailing Address - Fax:315-788-9186
Practice Address - Street 1:714 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-4032
Practice Address - Country:US
Practice Address - Phone:315-788-5650
Practice Address - Fax:315-788-9186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01026273Medicaid
NY54535AMedicare PIN