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Addiction Substance Use Disorder

Fort Drum, New York

Provider NPI: 1023092335

Provider Information:
Gender: M

Practice Location:
Tel: 315-772-8801  Fax: --

Business Mailing Address:
Tel: 315-463-6297  Fax: --

Entity Type: Individual


PrimaryCodeCategory/DescriptionStateLicense Number
N101YA0400XBehavioral Health & Social Service Providers
Addiction (Substance Use Disorder)
Y101YA0400XBehavioral Health & Social Service Providers

Other Provider Identifiers:

Code values:
01, Other | 02, Medicare Upin | 04, Medicare Id-Type Unspecified
05, Medicaid | 06, Medicare Oscar/Certification | 07, Medicare NSC | 08, Medicare Pin


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