Provider Demographics
NPI:1689991341
Name:UPSTATE CEREBRAL PALSY, INC
Entity Type:Organization
Organization Name:UPSTATE CEREBRAL PALSY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GENO
Authorized Official - Middle Name:
Authorized Official - Last Name:DECONDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-927-2117
Mailing Address - Street 1:1020 MARY ST
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-1930
Mailing Address - Country:US
Mailing Address - Phone:315-724-6907
Mailing Address - Fax:315-797-7249
Practice Address - Street 1:1020 MARY ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13501-1930
Practice Address - Country:US
Practice Address - Phone:315-724-6907
Practice Address - Fax:315-797-7249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-21
Last Update Date:2018-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019245-1252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1659525582Medicaid