=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104925031
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COUNTY OF OTSEGO
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2006
-----------------------------------------------------
Last Update Date | 03/29/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 242 MAIN STREET, 2ND FLOOR
-----------------------------------------------------
City | ONEONTA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13820-2527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-431-1030
-----------------------------------------------------
Fax | 607-431-1033
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 242 MAIN STREET, 2ND FLOOR
-----------------------------------------------------
City | ONEONTA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13820-2527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-431-1030
-----------------------------------------------------
Fax | 607-431-1033
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF COMMUNITY SERVICES
-----------------------------------------------------
Name | MS. SUSAN A MATT
-----------------------------------------------------
Credential | LCSW/CASAC
-----------------------------------------------------
Telephone | 607-433-2343
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------