Healthcare Provider Details

I. General information

NPI: 1053453886
Provider Name (Legal Business Name): CHILDREN'S HOME OF JEFFERSON COUNTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 07/08/2024
Certification Date: 07/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1704 STATE STREET
WATERTOWN NY
13601
US

IV. Provider business mailing address

PO BOX 6550
WATERTOWN NY
13601-6550
US

V. Phone/Fax

Practice location:
  • Phone: 315-788-7430
  • Fax: 315-785-5637
Mailing address:
  • Phone: 315-788-7430
  • Fax: 315-785-5637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number00009545
License Number StateNY

VIII. Authorized Official

Name: MICHELLE LYNN MONNAT
Title or Position: PRESIDENT AND CEO
Credential: LMHC
Phone: 315-777-9747