Provider Demographics
NPI:1457571515
Name:CHEMUNG COUNTY EARLY INTERVENTION PROGRAM
Entity Type:Organization
Organization Name:CHEMUNG COUNTY EARLY INTERVENTION PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EARLY INTERVENTION OFFICIAL
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:L
Authorized Official - Last Name:JERNIGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC-SLP
Authorized Official - Phone:607-737-5568
Mailing Address - Street 1:425 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14904-1762
Mailing Address - Country:US
Mailing Address - Phone:607-737-5569
Mailing Address - Fax:607-737-5480
Practice Address - Street 1:425 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14904-1762
Practice Address - Country:US
Practice Address - Phone:607-737-5569
Practice Address - Fax:607-737-5480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-30
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01760530Medicaid