Provider Demographics
NPI:1932316569
Name:SUNY POTSDAM
Entity Type:Organization
Organization Name:SUNY POTSDAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:GENA
Authorized Official - Middle Name:C
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC, NCC
Authorized Official - Phone:315-267-2330
Mailing Address - Street 1:605 COUNTY ROUTE 48
Mailing Address - Street 2:
Mailing Address - City:NORWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:13668-3222
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:44 PIERREPONT AVE.
Practice Address - Street 2:SUNY POTSDAM COUNSELING CENTER
Practice Address - City:POTSDAM
Practice Address - State:NY
Practice Address - Zip Code:13676
Practice Address - Country:US
Practice Address - Phone:315-267-2330
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002888-1302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization