Provider Demographics
NPI:1821721648
Name:CZELUSNIAK SERVISS, TIMOTHY (CASAC)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:CZELUSNIAK SERVISS
Suffix:
Gender:M
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4409 ELLSWORTH BLVD
Mailing Address - Street 2:
Mailing Address - City:MALTA
Mailing Address - State:NY
Mailing Address - Zip Code:12020-3357
Mailing Address - Country:US
Mailing Address - Phone:518-891-3950
Mailing Address - Fax:
Practice Address - Street 1:159 GLENWOOD DR
Practice Address - Street 2:
Practice Address - City:SARANAC LAKE
Practice Address - State:NY
Practice Address - Zip Code:12983-2385
Practice Address - Country:US
Practice Address - Phone:518-891-3950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-08
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY34114101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty