Provider Demographics
NPI:1699898635
Name:ST LAWRENCE COUNTY
Entity type:Organization
Organization Name:ST LAWRENCE COUNTY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:M
Authorized Official - Last Name:ULRICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-386-3562
Mailing Address - Street 1:80 STATE HIGHWAY 310
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CANTON
Mailing Address - State:NY
Mailing Address - Zip Code:13617-1493
Mailing Address - Country:US
Mailing Address - Phone:315-386-2167
Mailing Address - Fax:315-386-2435
Practice Address - Street 1:80 STATE HIGHWAY 310 STE 1
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:NY
Practice Address - Zip Code:13617-1436
Practice Address - Country:US
Practice Address - Phone:315-386-2167
Practice Address - Fax:315-386-2435
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST LAWRENCE COUNTY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-06
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 104100000X
NY251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00655803Medicaid
NY00655803Medicaid