Healthcare Provider Details

I. General information

NPI: 1275009490
Provider Name (Legal Business Name): NATURAL DYSTOPIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2018
Last Update Date: 10/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

147 RIDGE ST STE 2
GLENS FALLS NY
12801-3216
US

IV. Provider business mailing address

5 MOREHOUS DR
TICONDEROGA NY
12883-1110
US

V. Phone/Fax

Practice location:
  • Phone: 518-480-7208
  • Fax: 844-283-6959
Mailing address:
  • Phone: 518-586-4278
  • Fax: 844-283-6959

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: AKASHIA ROSS
Title or Position: PARTNER/OFFICE MANAGER
Credential:
Phone: 518-586-4278