Provider Demographics
NPI:1659389021
Name:CREDO COMMUNITY CENTER FOR TREATMENT OF ADDICTIONS INC
Entity Type:Organization
Organization Name:CREDO COMMUNITY CENTER FOR TREATMENT OF ADDICTIONS INC
Other - Org Name:CREDO COMMUNITY CENTER FOR THE TREATMENT OF ADDICTIONS INC
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:315-788-1530
Mailing Address - Street 1:595 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-1335
Mailing Address - Country:US
Mailing Address - Phone:315-788-1530
Mailing Address - Fax:315-788-3794
Practice Address - Street 1:595 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-1335
Practice Address - Country:US
Practice Address - Phone:315-788-1530
Practice Address - Fax:315-788-3794
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM2800X
NY070310744261QR0405X
NY324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02921011Medicaid