Healthcare Provider Details

I. General information

NPI: 1609265271
Provider Name (Legal Business Name): MENTAL HEALTH COUNSELING OF OSWEGO COUNTY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2015
Last Update Date: 11/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

188 S 3RD ST
FULTON NY
13069-1801
US

IV. Provider business mailing address

188 S 3RD ST
FULTON NY
13069-1801
US

V. Phone/Fax

Practice location:
  • Phone: 315-207-5435
  • Fax: 315-207-5435
Mailing address:
  • Phone: 315-207-5435
  • Fax: 315-410-5544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number837827415
License Number StateNY

VIII. Authorized Official

Name: TIFFANY JANE GENTILE
Title or Position: LMHC, DIRECTOR
Credential:
Phone: 315-207-5435