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General NPI Number Information
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NPI Number | 1497446413
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Entity Type | Organization
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Legal Business Name | COUNTRYSIDE MENTAL HEALTH COUNSELING PLLC
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Dates
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Enumeration Date | 05/19/2023
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Last Update Date | 05/19/2023
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Provider Practice Location Address
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Address Line | 7254 STATE ROUTE 5
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City | CLINTON
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State | NY
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Zip | 13323-3432
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Country | US
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Telephone | 315-557-8893
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 154
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City | CLINTON
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State | NY
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Zip | 13323-0154
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | DIRECTOR/CEO
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Name | KELSEY MOONEY
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Credential |
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Telephone | 315-557-8893
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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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