Provider Demographics
NPI:1104991009
Name:ULRICH, JAY S (LCSW-R)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:S
Last Name:ULRICH
Suffix:
Gender:M
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64 WELLER RD
Mailing Address - Street 2:
Mailing Address - City:NORTH BANGOR
Mailing Address - State:NY
Mailing Address - Zip Code:12966-3714
Mailing Address - Country:US
Mailing Address - Phone:518-481-6523
Mailing Address - Fax:
Practice Address - Street 1:209 PARK STREET
Practice Address - Street 2:CITIZEN ADVOCATES
Practice Address - City:MALONE
Practice Address - State:NY
Practice Address - Zip Code:12953
Practice Address - Country:US
Practice Address - Phone:518-483-3261
Practice Address - Fax:518-483-3383
Is Sole Proprietor?:No
Enumeration Date:2006-11-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR051436-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBB9107Medicare ID - Type Unspecified
NMS98989Medicare UPIN