Provider Demographics
NPI:1053602326
Name:ADVANTAGE MENTOR GROUP
Entity type:Organization
Organization Name:ADVANTAGE MENTOR GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:L
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-944-0130
Mailing Address - Street 1:12 CAROL STREET
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12205
Mailing Address - Country:US
Mailing Address - Phone:518-944-0130
Mailing Address - Fax:
Practice Address - Street 1:12 CAROL ST
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-3802
Practice Address - Country:US
Practice Address - Phone:518-944-0130
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-21
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health