MEDICARE: MID-HUDSON BEHAVIORAL HEALTH GROUP-LCSW, LLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)	73-114688	NY

General Provider Information

NPI Number	:	1881124972
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MID-HUDSON BEHAVIORAL HEALTH GROUP-LCSW, LLP

Provider Business Mailing Address
First Line	:	3 CLEVELAND DR
Second Line	:
City	:	POUGHKEEPSIE
State	:	NY
Zip	:	12601-6001
Country	:	US
Telephone Number	:	845-298-0264
Fax Number	:	845-297-0224

Provider Business Practice Location Address
First Line	:	942 ROUTE 376 STE 218
Second Line	:
City	:	WAPPINGERS FALLS
State	:	NY
Zip	:	12590-6493
Country	:	US
Telephone Number	:	845-226-6585
Fax Number	:	845-226-1483

Authorized Official
Title or Position	:	ASSOCIATE DIRECTOR
Name	:	MRS. LORI ANNE DRITZ
Credential	:	LCSW-R
Telephone Number	:	845-226-6585

Provider Enumeration Date	:	06/12/2017
Last Update Date	:	06/12/2017

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