Provider Demographics
NPI:1659651321
Name:NORTH COUNTRY CHILDREN'S CLINIC, INC.
Entity type:Organization
Organization Name:NORTH COUNTRY CHILDREN'S CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:AILEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-782-9450
Mailing Address - Street 1:238 ARSENAL ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-2504
Mailing Address - Country:US
Mailing Address - Phone:315-782-9450
Mailing Address - Fax:315-782-2643
Practice Address - Street 1:13180 US ROUTE 11
Practice Address - Street 2:
Practice Address - City:ADAMS CENTER
Practice Address - State:NY
Practice Address - Zip Code:13606-2276
Practice Address - Country:US
Practice Address - Phone:315-583-5200
Practice Address - Fax:315-583-5255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-25
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY080061-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00583702Medicaid