=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154406221
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEARL STREET COUNSELING CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2006
-----------------------------------------------------
Last Update Date | 11/18/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 109 STATE ST
-----------------------------------------------------
City | ALBANY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12207-1622
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-462-4320
-----------------------------------------------------
Fax | 518-462-4360
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 109 STATE ST
-----------------------------------------------------
City | ALBANY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12207-1622
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-462-4320
-----------------------------------------------------
Fax | 518-462-4360
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. GUY KUPERMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 518-462-4320
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 070611525
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------