Healthcare Provider Details

I. General information

NPI: 1154490944
Provider Name (Legal Business Name): CHAMPLAIN VALLEY PSYCHIATRIC ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 07/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 HAMMOND LANE SUITE A
PLATTSBURGH NY
12901-2003
US

IV. Provider business mailing address

11 HAMMOND LANE SUITE A
PLATTSBURGH NY
12901-2003
US

V. Phone/Fax

Practice location:
  • Phone: 518-561-0063
  • Fax: 518-561-0947
Mailing address:
  • Phone: 518-561-0063
  • Fax: 518-561-0947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: HAL IRA RUBIN
Title or Position: PHYSICIAN OWNER PARTNER
Credential: MD
Phone: 518-561-0063