Provider Demographics
NPI:1831145101
Name:COUNTY OF OTSEGO
Entity Type:Organization
Organization Name:COUNTY OF OTSEGO
Other - Org Name:OTSEGO COUNTY MENTAL HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF COMMUNITY SERVICES
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:MATT
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW/CASAC
Authorized Official - Phone:607-433-2343
Mailing Address - Street 1:242 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ONEONTA
Mailing Address - State:NY
Mailing Address - Zip Code:13820-2527
Mailing Address - Country:US
Mailing Address - Phone:607-433-2343
Mailing Address - Fax:607-433-6229
Practice Address - Street 1:242 MAIN ST
Practice Address - Street 2:
Practice Address - City:ONEONTA
Practice Address - State:NY
Practice Address - Zip Code:13820-2527
Practice Address - Country:US
Practice Address - Phone:607-433-2343
Practice Address - Fax:607-433-6229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6635100A261QM0801X
261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
115687OtherEXCELLUS BC/BS
NY03004473Medicaid
Z4118OtherEMPIRE BC/BS
NY03004473Medicaid
NY38830AMedicare ID - Type Unspecified