Healthcare Provider Details

I. General information

NPI: 1164778460
Provider Name (Legal Business Name): COUNCIL ON ALCOHOLISM & DRUG ABUSE OF SULLIVAN COUNTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2012
Last Update Date: 07/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 HAMILTON AVE
MONTICELLO NY
12701-1319
US

IV. Provider business mailing address

11 HAMILTON AVE
MONTICELLO NY
12701-1319
US

V. Phone/Fax

Practice location:
  • Phone: 845-794-8080
  • Fax: 845-791-1716
Mailing address:
  • Phone: 845-794-8080
  • Fax: 845-791-1716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number1437238706
License Number StateNY

VIII. Authorized Official

Name: IZETTA BRIGGS-BOLLING
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: LMHC, CASAC-G
Phone: 845-794-8080