Healthcare Provider Details

I. General information

NPI: 1205031499
Provider Name (Legal Business Name): TIOGA COUNTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2007
Last Update Date: 01/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1062 STATE ROUTE 38
OWEGO NY
13827
US

IV. Provider business mailing address

1062 STATE ROUTE 38 PO BOX 177
OWEGO NY
13827
US

V. Phone/Fax

Practice location:
  • Phone: 607-687-0200
  • Fax: 607-687-0248
Mailing address:
  • Phone: 607-687-0200
  • Fax: 607-687-0248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number071011080
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: SUE ROMANCZUK-SMELCER
Title or Position: DIRECTOR OF COMMUNITY SERVICES
Credential: PH.D, LCSW-R
Phone: 607-687-0200