Provider Demographics
NPI:1679698286
Name:MENTAL HEALTH SERVICES-ERIE COUNTY NORTHWEST CORPORATION I
Entity type:Organization
Organization Name:MENTAL HEALTH SERVICES-ERIE COUNTY NORTHWEST CORPORATION I
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FINANCE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CHURCH
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:716-882-2127
Mailing Address - Street 1:PO BOX 710
Mailing Address - Street 2:
Mailing Address - City:KENMORE
Mailing Address - State:NY
Mailing Address - Zip Code:14217-0710
Mailing Address - Country:US
Mailing Address - Phone:716-882-2127
Mailing Address - Fax:716-882-9277
Practice Address - Street 1:2495 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:KENMORE
Practice Address - State:NY
Practice Address - Zip Code:14217-2222
Practice Address - Country:US
Practice Address - Phone:716-882-2127
Practice Address - Fax:716-882-9277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02996876Medicaid
NY01556472Medicaid
NY00677734Medicaid