Healthcare Provider Details

I. General information

NPI: 1831344704
Provider Name (Legal Business Name): UNITED CEREBRAL PALSY ASSOC OF THE NORTH COUNTRY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2008
Last Update Date: 11/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 COMMERCE LANE
CANTON NY
13617
US

IV. Provider business mailing address

4 COMMERCE LANE
CANTON NY
13617
US

V. Phone/Fax

Practice location:
  • Phone: 315-386-8191
  • Fax: 315-386-1410
Mailing address:
  • Phone: 315-386-8191
  • Fax: 315-386-1410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number022617-1
License Number StateNY

VIII. Authorized Official

Name: JULIE ANNE WEAVER
Title or Position: DENTIAL HYGIENIST
Credential: RDH
Phone: 315-771-3794