Healthcare Provider Details

I. General information

NPI: 1255360046
Provider Name (Legal Business Name): COUNTY OF GREENE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2006
Last Update Date: 11/05/2021
Certification Date: 11/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 GREENE COUNTY OFFICE BLDG
CAIRO NY
12413-2868
US

IV. Provider business mailing address

905 GREENE COUNTY OFFICE BLDG
CAIRO NY
12413-2868
US

V. Phone/Fax

Practice location:
  • Phone: 518-622-9163
  • Fax: 518-622-8592
Mailing address:
  • Phone: 518-622-9163
  • Fax: 518-622-8592

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6864100A
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number1255360046
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier02994907
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer
# 2
Identifier00542489
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name: MR. JASON R FREDENBERG
Title or Position: DIRECTOR
Credential: PSY.D.
Phone: 518-622-9163