Provider Demographics
NPI:1891989786
Name:THE HOUSE OF THE GOOD SHEPHERD
Entity Type:Organization
Organization Name:THE HOUSE OF THE GOOD SHEPHERD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-235-7799
Mailing Address - Street 1:1550 CHAMPLIN AVE
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502-4828
Mailing Address - Country:US
Mailing Address - Phone:315-235-7780
Mailing Address - Fax:315-235-7789
Practice Address - Street 1:1550 CHAMPLIN AVE
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-4828
Practice Address - Country:US
Practice Address - Phone:315-235-7780
Practice Address - Fax:315-235-7789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-04
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYRID1658/VID00A01020251K00000X
NY8927040322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00356565Medicaid
NY01552327Medicaid