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General NPI Number Information
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NPI Number | 1275009490
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Entity Type | Organization
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Legal Business Name | NATURAL DYSTOPIA
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Dates
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Enumeration Date | 10/15/2018
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Last Update Date | 10/15/2018
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Provider Practice Location Address
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Address Line | 147 RIDGE ST STE 2
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City | GLENS FALLS
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State | NY
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Zip | 12801-3216
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Country | US
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Telephone | 518-480-7208
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Fax | 844-283-6959
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Provider Business Mailing Address
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Address Line | 5 MOREHOUS DR
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City | TICONDEROGA
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State | NY
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Zip | 12883-1110
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Country | US
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Telephone | 518-586-4278
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Fax | 844-283-6959
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Authorized Official
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Title or Position | PARTNER/OFFICE MANAGER
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Name | AKASHIA ROSS
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Credential |
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Telephone | 518-586-4278
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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