Provider Demographics
NPI:1639404064
Name:PROACTION OF STEUBEN AND YATES, INC.
Entity Type:Organization
Organization Name:PROACTION OF STEUBEN AND YATES, INC.
Other - Org Name:WIC PROGRAM
Other - Org Type:Other Name
Authorized Official - Title/Position:WIC PROGRAM DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:COGSWELL
Authorized Official - Suffix:
Authorized Official - Credentials:CDN
Authorized Official - Phone:607-776-1151
Mailing Address - Street 1:117 E STEUBEN ST
Mailing Address - Street 2:
Mailing Address - City:BATH
Mailing Address - State:NY
Mailing Address - Zip Code:14810-1636
Mailing Address - Country:US
Mailing Address - Phone:607-776-1151
Mailing Address - Fax:607-776-2803
Practice Address - Street 1:117 E STEUBEN ST
Practice Address - Street 2:
Practice Address - City:BATH
Practice Address - State:NY
Practice Address - Zip Code:14810-1636
Practice Address - Country:US
Practice Address - Phone:607-776-1151
Practice Address - Fax:607-776-2803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-02
Last Update Date:2009-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNO TAXONOMY CODE251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01168258Medicaid