Healthcare Provider Details

I. General information

NPI: 1669607206
Provider Name (Legal Business Name): TRI-COUNTY TBI ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2009
Last Update Date: 06/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 STATE ST
CARTHAGE NY
13619-1420
US

IV. Provider business mailing address

410 STATE ST
CARTHAGE NY
13619-1420
US

V. Phone/Fax

Practice location:
  • Phone: 315-519-1221
  • Fax: 315-519-1204
Mailing address:
  • Phone: 315-519-1221
  • Fax: 315-519-1204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. JOHN EDWARD YOUNG
Title or Position: OWNER/DIRECTOR
Credential:
Phone: 315-519-1221