Healthcare Provider Details

I. General information

NPI: 1376662320
Provider Name (Legal Business Name): ST LAWRENCE COUNTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 10/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 STATE HIGHWAY 310, SUITE 2
CANTON NY
13617-1476
US

IV. Provider business mailing address

80 STATE HIGHWAY 310, SUITE 2
CANTON NY
13617-1476
US

V. Phone/Fax

Practice location:
  • Phone: 315-386-2325
  • Fax: 315-386-2203
Mailing address:
  • Phone: 315-386-2325
  • Fax: 315-386-2203

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number4423600
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number4423600
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number4423600
License Number StateNY

VIII. Authorized Official

Name: DEBRA BRIDGES
Title or Position: FISCAL MANAGER
Credential: MBA
Phone: 315-229-3405