=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477667137
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MADISON COUNTY MENTAL HEALTH DEPARTMENT-CEDAR HOUSE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 201 CEDAR ST
-----------------------------------------------------
City | ONEIDA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13421-2111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-361-8413
-----------------------------------------------------
Fax | 315-361-8450
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 201 CEDAR ST
-----------------------------------------------------
City | ONEIDA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13421-2111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-361-8413
-----------------------------------------------------
Fax | 315-361-8450
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROGRAM DIRECTOR
-----------------------------------------------------
Name | MR. TOM KLEINKLAUS
-----------------------------------------------------
Credential | LMSW
-----------------------------------------------------
Telephone | 315-361-8413
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 6873300A
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------