Provider Demographics
NPI:1528631504
Name:SIMPLE SERENITY THERAPY CENTER
Entity type:Organization
Organization Name:SIMPLE SERENITY THERAPY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:DEFURIO
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-R
Authorized Official - Phone:315-806-3008
Mailing Address - Street 1:125 TEJAH AVE
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210
Mailing Address - Country:US
Mailing Address - Phone:315-806-3008
Mailing Address - Fax:
Practice Address - Street 1:125 TEJAH AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210
Practice Address - Country:US
Practice Address - Phone:315-313-4733
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-19
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04125137Medicaid