Healthcare Provider Details

I. General information

NPI: 1992468813
Provider Name (Legal Business Name): CCA WELLNESS NETWORK IPA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2021
Last Update Date: 10/18/2021
Certification Date: 10/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

196 DELAWARE AVE
DELMAR NY
12054-1230
US

IV. Provider business mailing address

196 DELAWARE AVE
DELMAR NY
12054-1230
US

V. Phone/Fax

Practice location:
  • Phone: 518-439-0033
  • Fax: 518-439-7167
Mailing address:
  • Phone: 518-439-0033
  • Fax: 518-439-7167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MRS. ALLISON CAPRERA
Title or Position: PRACTICE MANAGER, OWNER
Credential:
Phone: 860-455-3486