Healthcare Provider Details

I. General information

NPI: 1467432765
Provider Name (Legal Business Name): UNITED CEREBRAL PALSY ASSOCIATION OF THE NORTH COUNTRY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2006
Last Update Date: 01/22/2025
Certification Date: 01/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 COMMERCE LN
CANTON NY
13617-3739
US

IV. Provider business mailing address

4 COMMERCE LN
CANTON NY
13617-3739
US

V. Phone/Fax

Practice location:
  • Phone: 315-386-1156
  • Fax: 315-379-9388
Mailing address:
  • Phone: 315-386-1156
  • Fax: 315-379-9388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: ALEXANDER BRYDEN
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 315-379-8320