=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386071280
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OTSEGO COUNTY CHEMICAL DEPENDENCY CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2013
-----------------------------------------------------
Last Update Date | 10/09/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 242 MAIN ST
-----------------------------------------------------
City | ONEONTA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13820-2527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-431-1030
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 242 MAIN ST
-----------------------------------------------------
City | ONEONTA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13820-2527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-431-1030
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROGRAM MANAGER
-----------------------------------------------------
Name | MR. JUSTIN THALHEIMER
-----------------------------------------------------
Credential | LCSW, CASAC
-----------------------------------------------------
Telephone | 607-431-1030
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------