Provider Demographics
NPI:1386741551
Name:LEWIS COUNTY COMMUNITY SERVICES BOARD
Entity type:Organization
Organization Name:LEWIS COUNTY COMMUNITY SERVICES BOARD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:L
Authorized Official - Last Name:DYER
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:315-376-5958
Mailing Address - Street 1:7714 NUMBER THREE RD
Mailing Address - Street 2:
Mailing Address - City:LOWVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13367-3521
Mailing Address - Country:US
Mailing Address - Phone:315-376-5958
Mailing Address - Fax:315-376-5953
Practice Address - Street 1:7714 NUMBER THREE RD
Practice Address - Street 2:
Practice Address - City:LOWVILLE
Practice Address - State:NY
Practice Address - Zip Code:13367-3521
Practice Address - Country:US
Practice Address - Phone:315-376-5958
Practice Address - Fax:315-376-5953
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00657649Medicaid
NY000458OtherEXCELLUS