Provider Demographics
NPI:1679630909
Name:WATERLOO CSD
Entity type:Organization
Organization Name:WATERLOO CSD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SBA
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:S
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-539-1510
Mailing Address - Street 1:109 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:NY
Mailing Address - Zip Code:13165-1835
Mailing Address - Country:US
Mailing Address - Phone:315-539-1510
Mailing Address - Fax:315-539-1599
Practice Address - Street 1:109 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:NY
Practice Address - Zip Code:13165-1835
Practice Address - Country:US
Practice Address - Phone:315-539-1510
Practice Address - Fax:315-539-1599
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01383384Medicaid