Provider Demographics
NPI:1689780546
Name:MADISON COUNTY
Entity Type:Organization
Organization Name:MADISON COUNTY
Other - Org Name:MADISON COUNTY MENTAL HEALTH DEPARTMENT OUTPATIENT CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TEISHA
Authorized Official - Middle Name:M
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-R
Authorized Official - Phone:315-366-2327
Mailing Address - Street 1:138 NORTH COURT STREET
Mailing Address - Street 2:
Mailing Address - City:WAMPSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13163-0608
Mailing Address - Country:US
Mailing Address - Phone:315-366-2327
Mailing Address - Fax:315-366-2599
Practice Address - Street 1:138 NORTH COURT STREET
Practice Address - Street 2:
Practice Address - City:WAMPSVILLE
Practice Address - State:NY
Practice Address - Zip Code:13163-0608
Practice Address - Country:US
Practice Address - Phone:315-366-2327
Practice Address - Fax:315-366-2599
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6873100A261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00569860Medicaid
NY03004400Medicaid