Healthcare Provider Details

I. General information

NPI: 1003824855
Provider Name (Legal Business Name): COUNTY OF WAYNE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 03/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1519 NYE ROAD
LYONS NY
14489
US

IV. Provider business mailing address

1519 NYE ROAD
LYONS NY
14489
US

V. Phone/Fax

Practice location:
  • Phone: 315-946-5722
  • Fax: 315-946-7079
Mailing address:
  • Phone: 315-946-5722
  • Fax: 315-946-7079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number090511102
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number6898100A
License Number StateNY

VIII. Authorized Official

Name: MR. JAMES M HAITZ
Title or Position: DIRECTOR OF COMMUNITY SERVICES
Credential: LCSW-R
Phone: 315-946-5722