Provider Demographics
NPI:1992898670
Name:MENTAL HEALTH ASSOCIATION IN FULTON AND MONTGOM
Entity type:Organization
Organization Name:MENTAL HEALTH ASSOCIATION IN FULTON AND MONTGOM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JANINE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:DYKEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:518-762-5332
Mailing Address - Street 1:307-309 MEADOW STREET
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:12095
Mailing Address - Country:US
Mailing Address - Phone:518-762-5332
Mailing Address - Fax:518-762-6823
Practice Address - Street 1:11 MOHAWK PLACE
Practice Address - Street 2:
Practice Address - City:AMSTERDAM
Practice Address - State:NY
Practice Address - Zip Code:12010
Practice Address - Country:US
Practice Address - Phone:518-842-3717
Practice Address - Fax:518-842-0228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251K00000X
NYR7277431251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01304750Medicaid
NY3E7Medicaid