MEDICARE: SOUTHTOWNS MENTAL HEALTH COUNSELING PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	1041C0700X	Clinical Social Worker
2	111N00000X	Chiropractor
3	163W00000X	Registered Nurse
4	163WP0808X	Psychiatric/Mental Health Registered Nurse
5	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)
6	363LP0808X	Psychiatric/Mental Health Nurse Practitioner
7	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1306411244
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHTOWNS MENTAL HEALTH COUNSELING PC

Provider Business Mailing Address
First Line	:	42 LAKE ST STE D
Second Line	:
City	:	HAMBURG
State	:	NY
Zip	:	14075-4937
Country	:	US
Telephone Number	:	716-410-5390
Fax Number	:	716-422-9011

Provider Business Practice Location Address
First Line	:	42 LAKE ST STE D
Second Line	:
City	:	HAMBURG
State	:	NY
Zip	:	14075-4937
Country	:	US
Telephone Number	:	716-410-5390
Fax Number	:	716-422-9011

Authorized Official
Title or Position	:	OWNER
Name	:	MR. JASON SHEAR
Credential	:	LMHC
Telephone Number	:	716-410-5390

Provider Enumeration Date	:	05/24/2021
Last Update Date	:	08/09/2021

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