Provider Demographics
NPI:1588864656
Name:COMMUNITY LEAGUE, WASSAIC CHAPTER, NYSARC, INC.
Entity type:Organization
Organization Name:COMMUNITY LEAGUE, WASSAIC CHAPTER, NYSARC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROSE MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:CELLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-838-0515
Mailing Address - Street 1:1 SOUTH ST.
Mailing Address - Street 2:
Mailing Address - City:BEACON
Mailing Address - State:NY
Mailing Address - Zip Code:12508-2819
Mailing Address - Country:US
Mailing Address - Phone:845-838-0515
Mailing Address - Fax:845-831-2034
Practice Address - Street 1:1 SOUTH ST.
Practice Address - Street 2:
Practice Address - City:BEACON
Practice Address - State:NY
Practice Address - Zip Code:12508-2819
Practice Address - Country:US
Practice Address - Phone:845-838-0515
Practice Address - Fax:845-831-2034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-18
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01997722Medicaid