Healthcare Provider Details

I. General information

NPI: 1548262363
Provider Name (Legal Business Name): ITHACA ALPHA HOUSE CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 10/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

334 W STATE ST
ITHACA NY
14850-5432
US

IV. Provider business mailing address

38 EAST MAIN STREET PO BOX 724
TRUMANSBURG NY
14886
US

V. Phone/Fax

Practice location:
  • Phone: 607-273-5500
  • Fax: 607-273-1277
Mailing address:
  • Phone: 607-387-5535
  • Fax: 607-387-5526

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number070510837
License Number StateNY

VIII. Authorized Official

Name: MS. SUSAN M OAKS
Title or Position: CHIEF FINANCIAL OFFICERE
Credential:
Phone: 607-387-5535