Provider Demographics
NPI:1255360046
Name:COUNTY OF GREENE
Entity type:Organization
Organization Name:COUNTY OF GREENE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:R
Authorized Official - Last Name:FREDENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:518-622-9163
Mailing Address - Street 1:905 GREENE COUNTY OFFICE BLDG
Mailing Address - Street 2:
Mailing Address - City:CAIRO
Mailing Address - State:NY
Mailing Address - Zip Code:12413-2868
Mailing Address - Country:US
Mailing Address - Phone:518-622-9163
Mailing Address - Fax:518-622-8592
Practice Address - Street 1:905 GREENE COUNTY OFFICE BLDG
Practice Address - Street 2:
Practice Address - City:CAIRO
Practice Address - State:NY
Practice Address - Zip Code:12413-2868
Practice Address - Country:US
Practice Address - Phone:518-622-9163
Practice Address - Fax:518-622-8592
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-02
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6864100A101YM0800X
NY1255360046261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02994907Medicaid
NY00542489Medicaid