1891012266 NPI number — PRECIOUS MINDS CHILD/ADULT PSYCHIATRY SERVICES PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891012266 NPI number — PRECIOUS MINDS CHILD/ADULT PSYCHIATRY SERVICES PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRECIOUS MINDS CHILD/ADULT PSYCHIATRY SERVICES PLLC
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:
1891012266
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/26/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2504 GENESEE ST
Provider Second Line Business Mailing Address:
OFFICE FIRST FL
Provider Business Mailing Address City Name:
UTICA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13502-5832
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-507-2577
Provider Business Mailing Address Fax Number:
315-507-2643

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2504 GENESEE ST
Provider Second Line Business Practice Location Address:
OFFICE FIRST FL
Provider Business Practice Location Address City Name:
UTICA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13502-5832
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-507-2577
Provider Business Practice Location Address Fax Number:
315-507-2643
Provider Enumeration Date:
04/26/2010

Additional Information

Authorized Official

Authorized Official Last Name:
BROWN
Authorized Official First Name:
MORALES
Authorized Official Middle Name:
DENNIS
Authorized Official Title or Position:
PSYCHIATRIST
Authorized Official Telephone Number:
315-507-2577

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  255046-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 03193166 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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