Provider Demographics
NPI:1831344704
Name:UNITED CEREBRAL PALSY ASSOC OF THE NORTH COUNTRY INC
Entity type:Organization
Organization Name:UNITED CEREBRAL PALSY ASSOC OF THE NORTH COUNTRY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIAL HYGIENIST
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:WEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:315-771-3794
Mailing Address - Street 1:4 COMMERCE LANE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:NY
Mailing Address - Zip Code:13617
Mailing Address - Country:US
Mailing Address - Phone:315-386-8191
Mailing Address - Fax:315-386-1410
Practice Address - Street 1:4 COMMERCE LANE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:NY
Practice Address - Zip Code:13617
Practice Address - Country:US
Practice Address - Phone:315-386-8191
Practice Address - Fax:315-386-1410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-19
Last Update Date:2008-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022617-1124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01995615Medicaid