1558701854 NPI number — MARRIAGE AND FAMILY THERAPY SERVICES OF THE SOUTHERN TIER, P.C.

Table of content: (NPI 1558701854)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558701854 NPI number — MARRIAGE AND FAMILY THERAPY SERVICES OF THE SOUTHERN TIER, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARRIAGE AND FAMILY THERAPY SERVICES OF THE SOUTHERN TIER, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558701854
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/01/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 BRICK AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BINGHAMTON
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13901-2055
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
607-760-9520
Provider Business Mailing Address Fax Number:
607-723-9539

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
147 W GRAY ST
Provider Second Line Business Practice Location Address:
SUITE 217A
Provider Business Practice Location Address City Name:
ELMIRA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14901-3017
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
607-221-5303
Provider Business Practice Location Address Fax Number:
607-723-9539
Provider Enumeration Date:
07/01/2013

Additional Information

Authorized Official

Authorized Official Last Name:
DEVINCENTIS
Authorized Official First Name:
MELISSA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
607-221-5303

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X , with the licence number:  1084739 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 106H00000X , with the licence number: 000960 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 106H00000X , with the licence number: MF000684 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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