Healthcare Provider Details

I. General information

NPI: 1538455696
Provider Name (Legal Business Name): CHILDREN'S HOME OF JEFFERSON COUNTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2011
Last Update Date: 07/08/2024
Certification Date: 07/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 JB WISE PL
WATERTOWN NY
13601-2507
US

IV. Provider business mailing address

PO BOX 6550 1704 STATE STREET
WATERTOWN NY
13601-6550
US

V. Phone/Fax

Practice location:
  • Phone: 315-782-7445
  • Fax: 315-779-1184
Mailing address:
  • Phone: 315-788-7430
  • Fax: 315-785-5637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number03A2861
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number9298014A
License Number StateNY

VIII. Authorized Official

Name: MS. MICHELLE L MONNAT
Title or Position: PRESIDENT AND CEO
Credential: LMHC
Phone: 315-788-7430