Provider Demographics
NPI:1457478778
Name:CORTLAND COUNTY MENTAL HEALTH CLINIC
Entity Type:Organization
Organization Name:CORTLAND COUNTY MENTAL HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF ADMINISTRATIVE SERVICES
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JEREMEY
Authorized Official - Last Name:KILMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:607-758-6100
Mailing Address - Street 1:7 CLAYTON AVE
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:NY
Mailing Address - Zip Code:13045-2501
Mailing Address - Country:US
Mailing Address - Phone:607-758-6100
Mailing Address - Fax:607-758-6116
Practice Address - Street 1:7 CLAYTON AVE
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:NY
Practice Address - Zip Code:13045-2501
Practice Address - Country:US
Practice Address - Phone:607-758-6100
Practice Address - Fax:607-758-6116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01141148Medicaid