Provider Demographics
NPI:1548709025
Name:ITHACA ALPHA HOUSE
Entity type:Organization
Organization Name:ITHACA ALPHA HOUSE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:OAKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:607-387-5535
Mailing Address - Street 1:PO BOX 789
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14851-0789
Mailing Address - Country:US
Mailing Address - Phone:607-273-5500
Mailing Address - Fax:
Practice Address - Street 1:334 W STATE ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-5432
Practice Address - Country:US
Practice Address - Phone:607-273-5500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-17
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY099727-1261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder