Healthcare Provider Details

I. General information

NPI: 1891989786
Provider Name (Legal Business Name): THE HOUSE OF THE GOOD SHEPHERD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2007
Last Update Date: 09/24/2021
Certification Date: 09/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 CHAMPLIN AVE
UTICA NY
13502-4828
US

IV. Provider business mailing address

1550 CHAMPLIN AVE
UTICA NY
13502-4828
US

V. Phone/Fax

Practice location:
  • Phone: 315-235-7780
  • Fax: 315-235-7789
Mailing address:
  • Phone: 315-235-7780
  • Fax: 315-235-7789

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License NumberRID1658/VID00A01020
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number8927040
License Number StateNY

VIII. Authorized Official

Name: MR. BRIAN MCKEE
Title or Position: CEO
Credential:
Phone: 315-235-7799